Abstract

This study aims to analyse the eating patterns and nutrient intake in different eating patterns of elderly persons. This is a cross-sectional study with elderly people from Botucatu, São Paulo state, Brazil. The mean daily nutrient intake of individuals with high adherence to the eating patterns identified by factor analysis was analysed, comparing the intake by analysis of variance. Individuals with high adherence to the Healthy eating pattern had the highest mean intake of retinol, vitamin A and vitamin E. Individuals with high adherence to the eating pattern Snacks and weekend meal presented lower means of vitamin B12, vitamin C, phosphorus, and retinol intake and the highest means of iron, manganese and magnesium intake. Individuals with high adherence to Fruits had the lowest mean fibre intake. Individuals with high adherence to Light and whole foods had the highest means of vitamin C intake. Individuals with high adherence to Soft diet showed lower protein intake and increased added sugar intake. Individuals with high adherence to the Traditional eating pattern presented high means of nutrient intake. In general, a better characterization of the eating behaviour of elderly people who adhere to each of these eating patterns was possible.

Eating patterns; Micronutrients; Macronutrients; Food; Elderly

Introduction

With ageing, changes in nutritional status become more frequent due to factors that limit food consumption and nutrient utilization. These include physiological and oral cavity changes, economic and psychosocial factors, restriction of mobility and institutionalization¹1. Campos MTFS, Monteiro JBR, Ornelas APRC. Fatores que afetam o consumo alimentar e a nutrição do idoso. Rev Nutr 2000; 13(3):157-165.. In addition to these factors, the nutritional transition due to changes in eating patterns and a sedentary lifestyle has been shown to have a major impact on the health and nutritional status of the elderly²2. Silveira EA, Lopes ACS, Caiaffa WT. Avaliação Nutricional de Idosos. In: Kac G, Sichieri R, Gigante DP, organizadores. Epidemiologia nutricional. Rio de Janeiro: Fiocruz/Atheneu; 2007. p. 107..

In nutritional epidemiology, eating patterns are identified through statistical techniques of the reduction and/or aggregation of components. Pattern identification methods, such as exploratory methods, are based on empirical food data, which are aggregated on the basis of statistical analysis, with subsequent evaluation³3. Olinto MTA. Padrões alimentares: análise de componentes principais. In: Kac G, Sichieri R, Gigante DP, organizadores. Epidemiologia nutricional. Rio de Janeiro: Fiocruz/Atheneu; 2007. p. 213-225.. Principal component analysis (PCA) is one of the most commonly used statistical methods to empirically derive eating patterns³3. Olinto MTA. Padrões alimentares: análise de componentes principais. In: Kac G, Sichieri R, Gigante DP, organizadores. Epidemiologia nutricional. Rio de Janeiro: Fiocruz/Atheneu; 2007. p. 213-225.. The patterns derived from the exploratory method do not necessarily represent patterns of ideal diets⁴4. Hu FB. Dietary patterns analysis: A new direction in nutritional epidemiology. Curr Opin Lipidol 2002; 13(1):3-9.,⁵5. Jacques PF, Tucker KL. Are dietary patterns useful for understanding the role of diet in chronic disease? Am J Clin Nutr 2001; 73(1):1-2.. However, the specificity of this method offers the advantage of reflecting the real behaviour of a population group, providing useful information for the elaboration of nutritional guidelines⁶6. Brasil. Ministério da Saúde (MS). Departamento de Informática do SUS. Informações de Saúde. Brasília: MS; 2011.. Eating patterns may be a consequence of cultural, ethnic, and many environmental factors, including food availability, food purchasing and preparation, and numerous product advertisements⁵5. Jacques PF, Tucker KL. Are dietary patterns useful for understanding the role of diet in chronic disease? Am J Clin Nutr 2001; 73(1):1-2..

From a public health perspective, researchers stress the importance of evaluating food consumption through the use of various approaches to nutrient, food and food group analysis⁵5. Jacques PF, Tucker KL. Are dietary patterns useful for understanding the role of diet in chronic disease? Am J Clin Nutr 2001; 73(1):1-2.,⁷7. Marchioni DML. Estudos epidemiológicos em exposições nutricionais. In: Fisberg RM, Slater B, Marchioni DML, Martini LA, organizadores. Inquéritos alimentares. Métodos e bases científicos. Barueri: Manole; 2005. p. 87.. However, there is a shortage of studies in the literature that evaluate the diet using both approaches. Often, either eating patterns⁸8. Nettleton JA, Steffen LM, Mayer-Davis EJ, Jenny NS, Jiang R, Herrington DM, Jacobs Junior DR. Dietary patterns are associated with biochemical markers of inflammation and endothelial activation in the Multi-Ethnic Study of Atherosclerosis (MESA). Am J Clin Nutr 2006; 83(6):1369-1379.

9. Toledo ALA, Koifman RJ, Koifman S, Marchioni DML. Dietary patterns and risk of oral and pharyngeal cancer: a casecontrol study in Rio de Janeiro, Brazil. Cad Saude Publica 2010; 26(1):135-142.

10. Sichieri R. Dietary Patterns and Their Associations with Obesity in the Brazilian City of Rio de Janeiro. Obes Res 2002; 10(1):1-7.-¹¹11. Alves ALS, Olinto MTA, Costa JSD, Bairros FS, Balbinotti MAA. Padrões alimentares de mulheres adultas residentes em área urbana no sul do Brasil. Rev Saude Publica 2006; 40(5):865-873. or specific dietary components are analysed¹²12. Tucker LK. Micronutrient status and aging. Nutr Rev 1995; 53:9-15.

13. Michaelsson K, Melhus H, Bellocco R, Wolk A. Dietary calcium and vitamin D intake in relation to osteoporotic fracture risk. Bone 2003; 32(6):694-703.

14. Montilla RNG, Aldrighi JM, Marucci MFN. Relação cálcio/proteína da dieta de mulheres no climatério. AMB Rev Assoc Méd Bras 2004; 50:52-54.

15. Lopes ACS, Caiaffa WT, Sichieri R, Mingoti AS, Lima-Costa MF. Consumo de nutrientes em adultos e idosos em estudo de base populacional: Projeto Bambuí. Cad Saude Publica 2005; 21(4):1201-1209.-¹⁶16. Fisberg RM, Marchioni DML, Castro MA, Junior EV, Araújo MC, Bezerra IN, Pereira RA, Sichieri R. Ingestão inadequada de nutrientes na população de idosos do Brasil: Inquérito Nacional de Alimentação 2008-2009. Rev Saude Publica 2013; 47(1):222-230..

To date, few studies have used statistical methods to empirically identify eating patterns in elderly groups¹⁷17. Pala V, Sieri S, Masala G, Pali D, Panico S, Vneis P, Sacerdote C, Mattiello A, Galasso R, Salvini S, Ceroti M, Berrino F, Fuscon E, Tumino R, Frasca G, Riboli E, Trichopoulou A, Baibas N, Krogh V. Associations between dietary pattern and lifestyle, anthropometry and other health indicators in the elderly participants of the EPIC-Italy cohort. Nutr Metab Cardiovasc Dis 2006; 16(3):186-201.

18. Haveman-Nies A, Tucker KL, Groot LC, Wilson PW, Van Staveren WA. Evaluation of dietary quality in relationship to nutritional and lifestyle factors in elderly people of the US Framingham Heart Study and the European SENECA study. Eur J Clin Nutr 2001; 55(10):870-880.-¹⁹19. Lin H, Bermudez OI, Tucker KL. Dietary patterns of Hispanic elders are associated with acculturation and obesity. J Nutr 2003; 133(11):3651-3657.. In Brazil, a statistical analysis of the eating patterns and their components in the elderly population has not yet been published.

To increase the knowledge regarding the eating behaviour of the elderly, a group vulnerable to changes in nutritional status, this study proposes an unprecedented way to analyse eating patterns and nutrient intake by two different methodological approaches.

Methods

This is a cross-sectional epidemiological study, with a sample of 172 individuals aged 60 years or older residing in an urban area and enrolled in the basic health network of the city of Botucatu, SP, Brazil. Data from 172 individuals were randomly selected by stratified sampling among the 16 basic health units (BHUs) and family health strategies (FHS) in the city. Data were collected from March to June 2011, and participants answered a validated quantitative food frequency questionnaire (FFQ) for this population, which contained 71 food items²⁰20. Corrente JE, Marchioni DML, Fisberg R.M. Validation of a FFQ (Food Frequency Questionaire) for older people. J Life Sic 2013; 7(8):878-882..

The 172 individuals were a subsample of a sample of 355 individuals enrolled in primary care. This subsample is representative of the larger sample with regard to sociodemographic aspects, as demonstrated by the proportionality of the data of this study and those presented in Ferreira et al.²¹21. Ferreira PM, Papini SJ, Corrente JE. Diversity of eating patterns in older adults: A new scenario? Rev. Nutr 2014; 27(1):67-79.. Thus, it is possible that this subsample represents the population enrolled in the basic health network, considering the similarity in the sociodemographic profiles.

This study was approved by the Research Ethics Committee of the School of Medicine of Botucatu/Sao Paulo State University (UNESP) through protocol number 3560/2010.

The identification of eating patterns was performed in a previous study²¹21. Ferreira PM, Papini SJ, Corrente JE. Diversity of eating patterns in older adults: A new scenario? Rev. Nutr 2014; 27(1):67-79. using an exploratory factor analysis technique (PCA) with varimax rotation for food items. Individual consumption scores were calculated and divided into tertiles: low adherence, moderate adherence and high adherence to the eating pattern analysed²¹21. Ferreira PM, Papini SJ, Corrente JE. Diversity of eating patterns in older adults: A new scenario? Rev. Nutr 2014; 27(1):67-79..

For nutrient consumption calculation, the food composition data provided by the study “Inquérito de Saúde do Município de São Paulo (Health Survey of the Municipality of Sao Paulo; ISA- Capital)” of the University of São Paulo (USP) were used. All FFQ data were converted to nutrient intake using information on the portion size proportional to 100 grams of each nutrient, and these data were represented as the mean and standard deviation (SD). The following nutrients were evaluated: carbohydrate, protein, total fat, saturated fat, total fibre, added sugar, alcohol, vitamin D, vitamin C, retinol, vitamin A, folate, vitamin E, vitamin B12, calcium, phosphorus, magnesium, iron, sodium, potassium, selenium, copper, and manganese.

The total energy value (TEV) was calculated for each individual according to the following formula: TEV = ((4 kcal x protein (in grams) + (4 kcal x carbohydrate (in grams) + (9 kcal x total fat (in grams) + (7 kcal x alcohol (in grams)).

Comparisons of nutrient intake means, according to sex, were made regarding the high adherence to each of the patterns (identified as the highest tertile of adherence scores to each pattern identified in a previous study) using analysis of variance (ANOVA), followed by the energy-adjusted Tukey multiple comparison test (TEV) in cases of symmetrically distributed data. When the distribution was asymmetric, a generalized linear model with a gamma distribution was used, followed by the multiple Wald comparison, which was also adjusted by energy (TEV).

All analyses were performed using the SAS program, version 9.3. The level of significance was 5%.

Results and discussion

The sample consisted of 172 individuals aged sixty years or older, of whom 80 (46.51%) were male and 92 were female. The age ranged from 60 to 92 years, the mean age was 69.51 years (standard deviation = 7.90 years). This population lived with a mean per capita family income of 1.89 minimum wages. The majority of the individuals were white (86.55%) and had studied up to elementary school (40.12%).

The 6 eating patterns identified in the factor analysis²¹21. Ferreira PM, Papini SJ, Corrente JE. Diversity of eating patterns in older adults: A new scenario? Rev. Nutr 2014; 27(1):67-79. and that consistently reproduced the different eating characteristics of the elderly in the city of Botucatu were:

1. Healthy: Raw vegetables, vegetables, broccoli/cauliflower/cabbage, cooked vegetables, carrot, extra virgin olive oil, tomato, lettuce, fish, oats.

2. Snacks and weekend meal: Sausages, yellow cheeses, pizza/pancake, baked snacks, bacon/jerky beef, burger/nuggets/meatballs, fried snacks, butter, soda, French bread, pasta with meat, mayonnaise salad, desserts/sweets, potato/fried cassava.

3. Fruits: Avocado, guava, papaya, apple/pear, melon/watermelon, orange/bergamot/pineapple, banana.

4. Light and whole foods: Skimmed/semi-skimmed milk, whole wheat bread, natural juice without sugar, oats, extra virgin olive oil.

5. Soft diet: Baked potato/cassava, soup, French bread, whole milk, carrot, cooked corn meal.

6. Traditional: White rice, bean, lettuce, tomato.

A previous study presented the distribution of adherence to these eating patterns according to sociodemographic characteristics²¹21. Ferreira PM, Papini SJ, Corrente JE. Diversity of eating patterns in older adults: A new scenario? Rev. Nutr 2014; 27(1):67-79.. However, although the identification of these global patterns translates, in practical terms, the main foods that characterize the diet of these groups, it is not an evaluation method that can be used to describe the composition of nutrients in each eating pattern. For a complete evaluation of dietary intake, the present study proposes to quantitatively analyse the nutrients consumed by individuals with high adherence to each of the identified patterns, thereby expanding the understanding of the possible nutritional advantages or risks for the elderly when adhering to each of these patterns, as shown in Tables 1 and 2.

The means and pattern deviations of the intake of macro and micronutrients, respectively, of men and women with high adherence to each of the eating patterns are presented in Tables 1 and 2.

As shown in Tables 1 and 2, the high adherence to the Healthy pattern differed significantly from all other patterns because of the higher consumption of retinol in both sexes and vitamin A in males. In females, this pattern also presented the highest mean of vitamin A, not differing significantly from the Fruits and Light and whole foods patterns.

The high adherence to the Healthy pattern was also characterized by a greater intake of several nutrients. In this pattern, higher means were observed in both sexes for magnesium, iron, copper and manganese; in men, higher means of vitamin E, protein and selenium were observed, and in women the highest means were observed for vitamin B12.

Some of these results are expected because elements such as magnesium, iron, copper, manganese, vitamin E, vitamin A, protein and selenium are present in the foods that characterize the Healthy pattern.

For example, protein is present in both animal foods, such as fish, and foods of plant origin. Vitamin E and the aforementioned minerals are abundant in foods of plant origin. However, the higher means of retinol and vitamin B12 intake by individuals with high adherence to this pattern allow us to infer that it can supply larger amounts of important nutrients, such as those that are exclusive to foods of animal origin.

Considering that 10 to 30% of the elderly population may have impaired absorption of vitamin B12²²22. Galante AP, Schwartzman F, Voci SM. Aplicações práticas da Ingestão Dietética de referência. In: Rossi L, Caruso L, Galante AP, organizadores. Avaliação nutricional: Novas perspectivas. Rio de Janeiro: Roca; 2015. p.74. due to intrinsic factor deficiency, inflammatory bowel disease, surgery and medication (especially antibiotics, which destroy the intestinal flora)²³23. Calixto-Lima L, Reis NT. Interpretação de Exames Laboratoriais Aplicados à Nutrição Clínica. Rio de Janeiro: Editora Rubio; 2012., adherence to the Healthy pattern can contribute to a greater amount of this nutrient.

Fisberg et al., when assessing the prevalence of inadequate nutrient intake in the Brazilian elderly population, found a high prevalence of inadequacy in vitamin A intake, with percentages between 68% in women and 83% in men¹⁶16. Fisberg RM, Marchioni DML, Castro MA, Junior EV, Araújo MC, Bezerra IN, Pereira RA, Sichieri R. Ingestão inadequada de nutrientes na população de idosos do Brasil: Inquérito Nacional de Alimentação 2008-2009. Rev Saude Publica 2013; 47(1):222-230..

Considering the key role of vitamin A in the visual cycle, promotion of growth, epithelial cellular differentiation and maintenance, immune system activity and reproduction²⁴24. McLaren DS, Frigg M. Sight and Life Manual on Vitamin A Deficiency Desorders (VADD). Basel: Task Force Sight and Life; 2001, in addition to the low consumption of vitamin A-rich foods by the Brazilian elderly population¹⁶16. Fisberg RM, Marchioni DML, Castro MA, Junior EV, Araújo MC, Bezerra IN, Pereira RA, Sichieri R. Ingestão inadequada de nutrientes na população de idosos do Brasil: Inquérito Nacional de Alimentação 2008-2009. Rev Saude Publica 2013; 47(1):222-230.,²⁵25. Nascimento AL, Diniz AS, Arruda IKG. Deficiência de vitamina A em idosos do Programa de Saúde da Família de Camaragibe, PE, Brasil. Archivos Latinoamericanos de Nutricion 2007; 57(3):213-218., stimulating adherence to the Healthy pattern becomes strategic.

The development of guidelines and government programmes that encourage the consumption of fish, vegetables, oats and extra virgin olive oil, foods typical of this eating pattern, may be a good strategy for the prevention of vitamin A and vitamin B12 deficiencies, as well as ensuring intake of other micronutrients present in these foods.

As shown in Tables 1 and 2, a high adherence to the standard Snacks and weekend meal when compared to the Healthy and Light and whole foods patterns is characterized by lower means of vitamin C and vitamin B12 (in women) and phosphorus and retinol (in men).

This result demonstrates that even though the pattern Snacks and weekend meal contains foods of animal origin, it may not be a good source of important nutrients such as vitamin B12 and retinol.

On the other hand, the reduced means of vitamin C in high adherence to the pattern Snacks and weekend meal is an expected result because there is no source food of this vitamin found in this eating pattern.

The highest means of nutrients, such as iron (in both sexes) and magnesium and manganese (in females), in a high adherence to the pattern Snacks and weekend meal compared to a high adherence to the Fruits, Light and whole foods and Soft diet patterns are notable because this was only possible due to the isolated analysis of nutrients. This result may have occurred due to the consumption of meat and meat products and the presence of foods such as cereals and pasta that characterize this pattern.

The fortification of wheat and corn flours with iron and folic acid is mandatory and was established by Resolution RDC No. 344 of December 13, 2002²⁶26. Brasil. Resolução RDC nº 344, de 13 de dezembro de 2002. Áreas de atuação. Alimentos. Legislação específica da área por assunto. Regulamentos técnicos por assunto. Farinhas de trigo e/ou milho fortificadas com ferro. Diário Oficial da União 2002; 18 dez.. Although the supplemented amount of iron in 100 grams of flour was not elevated, this supplementation may also contribute to the higher levels of iron in a high adherence to the pattern Snacks and weekend meal.

Data from the Pesquisa de Orçamentos Familiares (Family Budget Survey; POF 2008-2009) show results similar to those found in this study, demonstrating that the mean intake of vitamin C was lower in groups of people who consume soda, pizza, stuffed biscuits and processed meats when compared to the average vitamin C intake of the population²⁷27. Instituto Brasileiro de Geografia e Estatística (IBGE). Análise do consumo alimentar pessoal no Brasil. POF 2008/2009. Rio de Janeiro: IBGE; 2011..

The data from POF (2008-2009) also indicated a higher mean folate intake in groups of people who consumed pizza and salty bread when compared to the mean folate intake of the population, correlating this finding with the probable fortification of flour with folate²⁷27. Instituto Brasileiro de Geografia e Estatística (IBGE). Análise do consumo alimentar pessoal no Brasil. POF 2008/2009. Rio de Janeiro: IBGE; 2011..

Men with a high adherence to the pattern Snacks and weekend meal consumed significantly lower amounts of saturated fat when compared to those with a high adherence to Fruit, Light and whole foods and Traditional patterns.

This result was not expected because this pattern is represented by several fatty foods such as sausage, yellow cheese, pizza/pancake, baked snack, bacon, hamburger, and butter, among others. There may have been an underestimation of the portion sizes of these foods.

It is known that in food consumption assessment studies, several factors may interfere with the quality of information, including gender, age, education level, the individual being concerned with social approval, and the patient’s own perception about healthy food²⁸28. Fisberg RM, Marchioni DML, Colucci ACA. Avaliação do consumo alimentar e da ingestão de nutrientes na prática clínica. Arq Bras Endocrinol Metab 2009; 53(5):617-624.,²⁹29. Novotny JA, Rumpler WV, Riddick H, Hebert JR, Rhodes D, Judd JT, Baer DJ, Mc Dowell M, Briefel R. Personality characteristics as predictors of underreporting of energy intake on 24- hour dietary recall interviews. J Am Diet Assoc 2003; 103(9):1146-1151..

Researchers recognize that sub-reporting remains a problem and may be associated with underestimation of portion size³⁰30. Young LR, Nestle MS. Portion sizes in dietary assessment: issues and policy Implications. Nutr Rev 1995; 53(6):149-158.

31. Tucker LK. Assessment of usual dietary intake in population studies of gene e diet interaction’. Nutrition, Metabolism & Cardiovascular Diseases 2007; 17(2):74-81.-³²32. Ferreira PM, Papini SJ, Corrente JE. Diversity of eating patterns and obesity in older adults-A new challenge. Health 2013; 5(8):23-28.. Tucker³¹31. Tucker LK. Assessment of usual dietary intake in population studies of gene e diet interaction’. Nutrition, Metabolism & Cardiovascular Diseases 2007; 17(2):74-81. notes that it is important to understand these sources of potential bias because they may lead to false conclusions about the observed associations.

Contrary to expectations, the method of analysis used in this study did not identify a higher intake of nutrients that are markers of an unhealthy diet, such as saturated fat and added sugar, by individuals with a high adherence to the pattern Snacks and weekend meal. However, the method proved to be effective in signalling lower means of vitamins and minerals in the high adherence to this pattern when compared to the other patterns.

As shown in Tables 1 and 2, a high adherence to the Fruits pattern was shown to have the lowest mean fibre intake for both sexes, differing significantly from most of the patterns (it did not significantly differ only from the pattern Soft diet).

Higher means of sodium and selenium were also observed in a high adherence to the pattern Fruits compared to a high adherence to the Light and whole foods and Soft diet patterns, as well as lower means of magnesium, folate, copper, and manganese when compared to a high adherence to the Healthy and Snack and weekend meal patterns.

In males, the mean saturated fat intake was higher in a high adherence to the Fruit pattern than in a high adherence to the Snacks and weekend meal pattern.

The isolated analyses of the nutrients for the Fruit pattern present unexpected results.

In the present study, it can be inferred that, inherent to this eating behaviour described by the preference for fruits, there is also the consumption of other types of food that can be fatty and caloric.

The high frequency of fruit consumption could also indicate a compensatory behaviour. It is known that individuals who recognize positive and negative effects of food may overestimate or underestimate the consumption of certain foods, so that the individual’s responses do not reflect the actual consumption information.

One reason for the smaller fibre means in the high adherence to this pattern when compared to the others may be that these individuals may have reported a high frequency of fruit consumption, but in smaller amounts than expected.

When analysing the portions of fruits consumed (considering a 70 kcal portion of the food pyramid, proposed by Philippi et al.³³33. Philippi ST, Latterza AR, Cruz ATR, Ribeiro LC. Pirâmide alimentar adaptada. Rev Nutr Campinas 1999; 12(1):65-80.), it was found that individuals of both sexes with high adherence to the Fruit pattern consumed an average of only 2.62 (SD = 2.56) and a median of 2.06 servings of fruits per day. On the other hand, individuals with a high adherence to the Healthy, Soft diet, Snacks and weekend meal, Traditional and Light and whole foods patterns consumed, respectively, means of 2.74 (SD = 1.87), 2.99 (SD = 2.64), 3.08 (SD = 3.11), 3.27 (SD = 2.21) and 5.12 (SD = 2.83) servings of fruit per day.

Although the average number of portions consumed in a high adherence to the Fruits pattern was lower than the other patterns, it differed significantly only in relation to the Light and whole foods pattern (p = 0.012, by the Kruskal-Wallis test). In the total sample, the mean intake of fruit portions was 2.85 (SD = 2.41), and the median was 2.46 servings per day.

Importantly, when identifying the eating patterns by principal component analysis, the frequency of food intake was considered, not the evaluation of the amount of food consumed.

Other studies have highlighted the insufficient consumption of fruits and vegetables by the Brazilian elderly population¹⁶16. Fisberg RM, Marchioni DML, Castro MA, Junior EV, Araújo MC, Bezerra IN, Pereira RA, Sichieri R. Ingestão inadequada de nutrientes na população de idosos do Brasil: Inquérito Nacional de Alimentação 2008-2009. Rev Saude Publica 2013; 47(1):222-230.,³⁴34. Silveira EA, Martins BB, Abreu LRS, Cardoso CKS. Baixo consumo de frutas, verduras e legumes: fatores associados em idosos em capital no Centro-Oeste do Brasil. Cien Saude Colet 2015; 20(12):3689-3699.

35. Oliveira SO, Lacerda LNL, Santos LC, Lopes ACS, Câmara AMCS, Menzel HJK, Horta PM. Consumo de frutas e hortaliças e as condições de saúde de homens e mulheres atendidos na atenção primária à saúde. Cien Saude Colet 2015; 20(8):2313-2322.

36. Jaime PC, Figueiredo ICR, Moura EC, Malta DC . Fatores associados ao consumo de frutas e hortaliças no Brasil. Rev Saude Publica 2009; 43(2):57-64.-³⁷37. 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..

Fisberg et al. observed that the consumption of fruits and vegetables by the Brazilian elderly population was approximately one-third of the amount recommended by the Food Guide for the Brazilian Population ( ≥ 400 g/day)¹⁶16. Fisberg RM, Marchioni DML, Castro MA, Junior EV, Araújo MC, Bezerra IN, Pereira RA, Sichieri R. Ingestão inadequada de nutrientes na população de idosos do Brasil: Inquérito Nacional de Alimentação 2008-2009. Rev Saude Publica 2013; 47(1):222-230..

As shown in Tables 1 and 2, a high adherence to the Light and whole foods pattern in females in comparison to a high adherence to all other patterns is characterized by higher mean values of vitamin C. Additionally, the high adherence to this pattern is characterized by higher means of retinol and vitamin B12.

A high adherence to the Soft diet pattern presents lower means of protein and fibre and higher means of added sugar when compared to the other patterns. These results are expected for a pattern of these types of foods.

The high adherence to the Soft diet pattern is more prevalent in the female sex and in the elderly, and these characteristics are justified both by economic issues and ease of preparation or by issues related to changes in masticatory capacity due to the use of dental prostheses or even swallowing problems arising from pathologies²¹21. Ferreira PM, Papini SJ, Corrente JE. Diversity of eating patterns in older adults: A new scenario? Rev. Nutr 2014; 27(1):67-79..

The Traditional pattern received this name because it reflects the basic diet of the Brazilian population, such as the “rice and beans” combinations and the “lettuce and tomato” salad.

A high adherence to the Traditional pattern presents, in general, higher means of nutrient consumption when compared to the others, but it did not differ significantly in relation to most of the patterns. This pattern was highlighted only in females when compared to the Soft diet pattern because it presents higher means of protein; when compared to the Healthy pattern it presents a higher consumption of vitamin D.

The results of the component analysis of the diet demonstrate that adhering more to the Traditional pattern can provide a larger supply of nutrients that are important for the proper nutritional status of the elderly, such as vitamin D and protein. Ferreira et al. (2014) confirmed that there is a fairly homogeneous distribution of this pattern in the population because these foods are the most frequently consumed by most individuals²¹21. Ferreira PM, Papini SJ, Corrente JE. Diversity of eating patterns in older adults: A new scenario? Rev. Nutr 2014; 27(1):67-79..

Recent studies carried out in Brazil show that the intake of vitamins and minerals by the elderly is below the recommended values. These studies found a high prevalence of inadequacy, mainly of vitamins A, E and D and of minerals such as calcium, magnesium and iron¹⁶16. Fisberg RM, Marchioni DML, Castro MA, Junior EV, Araújo MC, Bezerra IN, Pereira RA, Sichieri R. Ingestão inadequada de nutrientes na população de idosos do Brasil: Inquérito Nacional de Alimentação 2008-2009. Rev Saude Publica 2013; 47(1):222-230.,³⁸38. Barbosa AM, Nunes IFOC, Carvalho LR, Figuerêdo RG, Nogueira AMT, Carvalho CMRG. Ingestão alimentar de cálcio e vitamina D e associação com o nível de escolaridade na pessoa idosa. Demetra 2013; 8(2):173-181.

39. Abreu WC, Franceschini SCC, Tinoco AL, Pereira CAS, Silva MMS. Inadequação no consumo alimentar e fatores interferentes na ingestão energética de idosos matriculados no programa municipal da terceira idade de viçosa (MG). Revista baiana de Saúde Pública 2008; 32(2):190-202.-⁴⁰40. Souza LB, Corrente JE, Papini SJ. Prevalence of Inadequacy Intake for Older People: The Use of National Cancer Institute (NCI) Method. Food and Nutrition Sciences 2013; 4:25-30..

Strategic planning for qualitative changes in eating may help to satisfactorily provide a greater supply of vitamins and minerals. The new Food Guide for the Brazilian Population⁴¹41. Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira. Brasília: MS; 2014., for example, calls for more general dietary recommendations, such as “making raw or minimally processed food as a staple food”, “limit the consumption of processed foods,” and “avoid consuming ultra-processed food”, among others.

These general guidelines can help minimize much of the negative impacts of nutritionally poor foods, such as ultra-processed foods, which should be replaced by foods rich in vitamins and minerals such as fruits and vegetables.

Some limitations inherent to food consumption studies should be evaluated and discussed for a better interpretation of the results of this study.

The amount of nutrient intake can be influenced by the total amount of energy consumed⁴²42. Willett W, Stampfer M. Implications of total energy intake for epidemiologic Analyses. In: Willett, W, organizador. Nutritional epidemiology. New York: Oxford University Press; 1998. p. 514.. Therefore, in this study, before interpreting the nutrient intake data, a strategy for energy adjustment was used⁴³43. Willett WC, Howe GR, Kushi LH. Adjustment for total energy intake in epidemiologic studies. Am J Clin Nutr 1997; 65(Supl. 4):1220-1228.

44. Atwater WO, Benedict FG. Experiments on the metabolism of matter and energy in the human body, 1898–1900. Washington: Government Printing Office; 1902. No. 109.-⁴⁵45. Food and Agriculture Organization (FAO). Food energy – methods of analysis and conversion factors. Report of a technical workshop. Rome: Food and Nutrition Paper; 2003.. Beaton⁴⁶46. Beaton GH. Approaches to analysis of dietary data: relationship between planned analyses and choice of methodology. Am J Clin Nutr 1994; 59(1):253-261. emphasizes that food intake cannot be estimated without errors, and probably will never be.

The FFQ is a recognized method for characterizing the typical diet, but, like other food surveys, it may underestimate or overestimate the information collected regarding consumption⁷7. Marchioni DML. Estudos epidemiológicos em exposições nutricionais. In: Fisberg RM, Slater B, Marchioni DML, Martini LA, organizadores. Inquéritos alimentares. Métodos e bases científicos. Barueri: Manole; 2005. p. 87.,²⁸28. Fisberg RM, Marchioni DML, Colucci ACA. Avaliação do consumo alimentar e da ingestão de nutrientes na prática clínica. Arq Bras Endocrinol Metab 2009; 53(5):617-624..

To reduce recall bias, a frequent phenomenon in patients of advanced age, the participation of a companion or caregiver was requested in all interviews. When it was not possible to rely on the participation of a companion in the interview, a larger amount of time was taken for the interview, up to 1 ½ hours when necessary.

In recognizing the difficulties of estimating the typical diet, the present study did not evaluate the individual’s typical intake in a precise way, but rather aimed to increase the knowledge regarding the heterogeneous dietary characteristics observed in this group of elderly people in Botucatu.

Despite efforts over the last half century, there is still a need for an international definition of harmonized methods and data collection for assessing the food consumption of this population⁴⁵45. Food and Agriculture Organization (FAO). Food energy – methods of analysis and conversion factors. Report of a technical workshop. Rome: Food and Nutrition Paper; 2003..

Detailing the nutritional components of each food pattern presented expected results, which corroborated the characteristics of each pattern. On the other hand, some unexpected results were also found, which contributes to broaden the discussion about the challenge of evaluating food consumption, with special attention to methodological issues.

Adhering to eating patterns with characteristics similar to the Healthy, Light and whole foods and Traditional patterns can provide greater macronutrient and micronutrient inputs, contributing to the reduction of the inadequate intake of important nutrients for the health of the elderly population. In contrast, adhering to eating patterns similar to the Snacks and weekend meal pattern may contribute to a reduced intake of vitamins and minerals.

In this study, it was possible to better characterize food behaviour, broadening the understanding about the possible nutritional benefits and risks for the elderly who adhere to each of these food patterns.

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