Abstract

This article describes a systematic review of the literature on studies that have used the scores method proposed by Fornés et al. (2002) to evaluate food consumption and discuss the method from the perspective of food pattern assessment. The search of the Medline, Lilacs and Scielo databases was limited to the English, Portuguese and Spanish languages and to articles published from 2002 to 2016. The inclusion criterion was studies that used the scores method proposed by Fornés et al. to evaluate food consumption. The original search found 8300 items. After reading titles and abstracts and applying the exclusion criteria, 14 articles were selected. The articles evaluating food pattern used different groupings and examined associations with anthropometric, socioeconomic and biochemical variables. It was concluded that the scores method is able to evaluate food patterns and enables associations to be established between anthropometric, biochemical, socioeconomic and clinical variables and the components of the study diet/food grouping to which the individual was exposed.

Food consumption; Human eating behaviour

Introduction

The food pattern of Brazil’s population has undergone changes characterised by increasing intake of foods that are high energy density, poor in fibres and rich in saturated fats, trans fats and sugars. These, in association with physical inactivity, smoking and alcohol abuse, have been identified as independent predictors of several diseases¹1. McNaughton SA, Mishra GD, Brunner EJ. Food patterns associated with blood lipids are predictive of coronary heart disease: the Whitehall II study. Br J Nutr 2009; 102(4):619-624.

2. Link LB, Canchola AJ, Bernstein L, Clarke CA, Stram DO, Ursin G, Horn-Ross PL. Dietary patterns and breast cancer risk in the California Teachers Study cohort. Am J Clin Nutr 2013; 98(6):1524-1532.

3. Monteiro CA, Levy RB, Claro RM, Castro IRS, Cannons G. Increasing consumption of ultra-processed foods and likely impact on human health. Evidence from Brazil. Public Health Nutr 2011; 14(1):5-13.^-44. Levy RB, Claro RM, Mondini L, Sichieri R, Monteiro C A. Regional and socioeconomic distribution of household food availability in Brazil, in 2008-2009. Rev Saude Publica 2012; 46(1):6-15..

The World Health Organisation⁵5. World Health Organization (WHO). Report of a Joint FAO/WHO Consultation. Preparation and Use of Food-Based Dietary Guidelines. Geneva: WHO; 1998. has suggested that population food consumption is better assessed by way of food patterns, considering that individuals do not consume isolated nutrients or foods. Northstone et al.⁶6. Northstone K, Smith AD, Cribb VL, Emmett PM. Dietary patterns in UK adolescents obtained from a dual-source FFQ and their associations with socio-economic position, nutrient intake and modes of eating. Public Health Nutr 2014; 17(7):1476-1485. argue that assessment by isolated nutrients does not reflect the multifactorial nature of human diet. In that light, there is growing interest in this line of investigation into consumption of food groups considered to define healthy and unhealthy food patterns⁷7. Liese AD, Krebs-Smith SM, Subar AF, George SM, Harmon BE, Neuhouser ML, Boushey CJ, Schap TE, Reedy J. The Dietary Patterns Methods Project: Synthesis of Findings across Cohorts and Relevance to Dietary Guidance. J Nutr 2015; 1(2):393-402.^,88. Azevedo ECC, Dias FMRS, Diniz AS, Cabral PC. Consumo alimentar de risco e proteção para as doenças crônicas não transmissíveis e sua associação com a gordura corporal: um estudo com funcionários da área de saúde de uma universidade pública de Recife (PE), Brasil. Cien Saude Colet 2014; 19(5):1613-1622..

Food patterns characterised by a set or group of foods consumed by a given population can be specified theoretically, by grouping nutritional variables, such as foods and nutrients, according to previously chosen nutritional criteria, or empirically, by reducing the variables to the smallest number by means of statistical analysis and then evaluating them⁹9. Newby PK, Tucker KL. Empirically derived eating patterns using factor or cluster analysis: a review. Nutr Rev 2004; 62(5):177-203..

As an alternative for analysing overall diet, Fornés et al.¹⁰10. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18. proposed the scores method, which is conducted by awarding points to foods in the diet, by categories grouped according to the study objectives. Note that in dictionaries, “score” is synonymous with “points”, “a value that needs no unit of measurement”.

When applied to a population group, this makes it possible to determine consumption patterns by food groups of interest to that study and, once the score is established, as it is a numerical value, it becomes possible to draw comparisons with outcomes of interest to that study¹¹11. Sotero AM, Cabral PC, Silva GAP. Socioeconomic, cultural and demographic maternal factors associated with dietary patterns of infants. Rev. paul. pediatr. 2015; 33(4):445-452..

The scores method for evaluating food consumption is a relatively simple measure that reflects qualitative and/or quantitative aspects of diet. Higher scores mean greater consumption of a given food group, which permits statistical analyses of the association between patterns of consumption and explanatory variables¹²12. Neto ACB, Andrade MIS, Lima VLM, Diniz ASD. Peso corporal e escores de consumo alimentar em adolescentes no nordeste brasileiro. Rev. paul. pediatr.2015; 33(3):318-325..

In view of the foregoing, this study reviewed the literature on studies that have examined food consumption using the scores method proposed by Fornés et al.¹⁰10. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18., and discussed by the method from the perspective of food pattern assessment.

Methods

A systematic literature review was conducted, drawing on an article search based on the pre-defined question: “Is the scores method a tool used to evaluate food consumption with a view to identifying food patterns and does it enable their association with other variables to be determined?” In order to organise the study question, research strategy and selection criteria, an expanded version of the Population, Intervention, Comparison, Outcome (PICO) model¹³13. Centre for Reviews and Dissemination. Systematic reviews: CRD’s guidance for undertaking reviews in health care. York. 2008 [cited 2016 Ago 01]. Available from: https://www.york.ac.uk/media/crd/Systematic_Reviews.pdf
https://www.york.ac.uk/media/crd/Systema... was used: the PICOCS model, which also contemplates Context and Study design.

Search strategy

Articles of interest were identified in April 2016 in the following electronic databases: the Medical Literature Library of Medicine (Medline), via PubMed; the Scientific Electronic Library Online (SciELO); and Latin American and Caribbean Health Sciences Literature (Lilacs), via the Virtual Health Library (BVS). From these, studies published from 2002 until 01 December 2016 were selected. It was decided to search from the start of 2002, because that was when Fornés’ first paper on the scores method was published. The search was restricted to the Spanish, English and Portuguese languages.

The following keywords and corresponding terms in English were selected from among the Health Sciences Descriptors (DECS): hábitos alimentares (food habits), consumo de alimentos (food consumption) and ingestão de alimentos (food intake). The term escore (score*) was also included as delimiting the method. The logical operators AND and OR were used to combine the terms chosen for the publication search.

Eligibility criteria

Studies that used the scores method proposed by Fornés et al.¹⁰10. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18. to evaluate food consumption were considered eligible. Review articles, duplicate articles in the data bases and studies that did not use the scores method proposed by Fornés et al. were excluded.

Selection of articles

Two researchers, working independently, evaluated the articles arising from the initial search strategy by title and abstract, according to the previously established eligibility and exclusion criteria. Any divergences were resolved by consensus. In the event of continuing disagreement, an evaluator with expertise was consulted.

Data extraction

For the narrative summaries of the articles of interest, the following data were extracted: year of publication; journal and study year; study location; target public; sample size; objectives; study variables; consumption patterns used, identifying the food group categories; and the associations observed between the scores formed for the food patterns and the variables (Chart 1).

The scores method

As this study focused on reviewing application of the scores method conceived by Fornés et al.¹⁰10. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18., the authors had to consider its methodology carefully in order to understand and explain the process by which it is applied. Application was systematised step by step as illustrated in Figure 1. The flow diagram shows how the consumption frequency categories of the Food Frequency Questionnaire (FFQ) are converted into scores and consumption patterns in order to study associated factors.

Evaluating methodological quality

The articles included were evaluated by two of the authors in accordance with the criteria of the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology)¹⁴14. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, STROBE Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007; 335(7624):806-808. initiative, in which scores of 1 or 0 are awarded on each of the 22 criteria, depending on whether they are considered, respectively, to be met or unmet¹⁵15. Mendes KG, Theodoro H, Rodrigues AD, Olinto MTA. Prevalência de síndrome metabólica e seus componentes na transição menopáusica: uma revisão sistemática. Cad. Saude Publica 2012; 28(8):1423-1437.. After evaluation by the criteria, each article received a score from 0 to 22 from each reviewer. The final score was calculated as the mean of the scores awarded by all reviewers. The articles were classified in order of final scores. In order to evaluate the quality of the articles, the overall scores were converted into percentages, which were classified into 3 categories, following Mataratzis et al.¹⁶16. Mataratzis PSR, Accioly E, Padilha PC. Deficiências de micronutrientes em crianças e adolescentes com anemia falciforme: uma revisão sistemática. Rev. Bras. Hematol. Hemoter 2010; 32(3):247-256.: A – when the study met more than 80% of the STROBE criteria; B – when 50%-80% of the STROBE criteria were met; and C – when fewer than 50% of the criteria were met.

Results

In all, 8,300 bibliographical references were found and their titles were evaluated. Of these, 433 were selected and their abstracts, read; those whose content did not meet the selection criteria were excluded. After that stage, the complete texts of 91 articles were read. After detailed review, 14 articles were considered appropriate and their results were recorded systematically (Figure 2). The evaluation of methodological quality, on the STROBE¹⁴14. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, STROBE Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007; 335(7624):806-808. criteria, revealed that 92.9% (n = 13) attained a B quality score (Table 1).

Chart 1 gives a summary of the data of interest to this review (authorship, year of publication, study location, number of participants, study objectives, study variables, food consumption patterns used and main results) drawn from the 14 articles selected after complete review. All the studies were cross-sectional in design. The first study was published in 2002, by Fornés et al.¹⁰10. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18., who proposed the scores method and examined correlations between protective food consumption patterns and cardiovascular risk and lipid profile. The method was used by other researchers, but related publications did not begin until 2006¹⁷17. Neumann AICP, Shirassu MM, Fisberg RM. Consumo de alimentos de risco e proteção para doenças cardiovasculares entre funcionários públicos. Rev. Nutr. 2006; 19(1):19-28.^,1818. Moraes SA, Rosas JB, Mondini L, Freitas ICM. Prevalência de sobrepeso e obesidade e fatores associados em escolares de área urbana de Chilpancingo, Guerrero, México, 2004. Cad Saude Publica 2006; 22(6):1289-1301.. Since then, an average of one article using this method has been published per year.

The scores method

Most of the articles included in this review were produced in Brazil (n = 13; 92.8%)⁸8. Azevedo ECC, Dias FMRS, Diniz AS, Cabral PC. Consumo alimentar de risco e proteção para as doenças crônicas não transmissíveis e sua associação com a gordura corporal: um estudo com funcionários da área de saúde de uma universidade pública de Recife (PE), Brasil. Cien Saude Colet 2014; 19(5):1613-1622.

9. Newby PK, Tucker KL. Empirically derived eating patterns using factor or cluster analysis: a review. Nutr Rev 2004; 62(5):177-203.

10. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18.

11. Sotero AM, Cabral PC, Silva GAP. Socioeconomic, cultural and demographic maternal factors associated with dietary patterns of infants. Rev. paul. pediatr. 2015; 33(4):445-452.^-1212. Neto ACB, Andrade MIS, Lima VLM, Diniz ASD. Peso corporal e escores de consumo alimentar em adolescentes no nordeste brasileiro. Rev. paul. pediatr.2015; 33(3):318-325.^,1717. Neumann AICP, Shirassu MM, Fisberg RM. Consumo de alimentos de risco e proteção para doenças cardiovasculares entre funcionários públicos. Rev. Nutr. 2006; 19(1):19-28.^,1919. Oliveira LPM, Pinheiro SMC, Assis AMO, Silva MCM, Santana MLP, Santos NS, Pinheiro SMC, Barreto ML, Souza CO. Fatores associados a excesso de peso e concentração de gordura abdominal em adultos na cidade de Salvador, Bahia, Brasil. Cad Saude Publica 2009; 25(3):570-582.

20. Esteves EA, Rodrigues CAA, Paulino EJ. Ingestão dietética de cálcio e adiposidade em mulheres adultas. Rev Nutr 2010; 23(4):543-552.

21. Silva EFR, Lewi DS, Vedovato GM, Garcia VRS, Tenore SB, Bassichetto KC. Estado nutricional, clínico e padrão alimentar de pessoas vivendo com HIV/Aids em assistência ambulatorial no município de São Paulo. Rev. bras. epidemiol. 2010; 13(4):677-688.

22. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545.

23. Saldiva SRDM, Silvia LFF, Saldiva PHN. Avaliação antropométrica e consumo alimentar em crianças menores de cinco anos residentes em um município da região do semiárido nordestino com cobertura parcial do programa bolsa família. Rev Nutr 2010; 23(2):221-229.

24. Pinho CPS, Diniz AS, Arruda Ilma KG, Lira PIC, Cabral PC, Siqueira LAS, Batista Filho M. Consumo de alimentos protetores e preditores do risco cardiovascular em adultos do estado de Pernambuco. Rev Nutr 2012; 25(3):341-351.

25. Pinho PM, Machado LM, Torres RS, Carmin SE, Mendes WA, Silva AC, Araújo MS, Ramos EMLS. Síndrome metabólica e sua relação com escores de risco cardiovascular em adultos com doenças crônicas não transmissíveis. Rev. Soc. Bras. Clín. Méd. 2014; 12(1):22-30.^-2626. Mondini L, Levy RB, Saldiva SRDM, Venâncio SI, Stefanini MLR. Prevalência de sobrepeso e fatores associados em crianças ingressantes no ensino fundamental em um município da região metropolitana de São Paulo, Brasil. Cad Saude Publica 2007; 23(8):1825-1834. using different sample sizes (ranging from 50 to 2,866 individuals), FFQ types (semi-quantitative and qualitative) and definitions of food consumption pattern (by risk for and protection against CVDs and CNCDs, as healthy and unhealthy and also by food groups resulting from different grouping procedures).

The journals with most articles published were Cadernos de Saúde Pública and Revista de Nutrição with four (28.6%) publications each. Although the groups studied varied from children under 5 years of age through to individuals over 60 years old, in 71.4% (n = 10) of the studies, the target public was made up of adults⁸8. Azevedo ECC, Dias FMRS, Diniz AS, Cabral PC. Consumo alimentar de risco e proteção para as doenças crônicas não transmissíveis e sua associação com a gordura corporal: um estudo com funcionários da área de saúde de uma universidade pública de Recife (PE), Brasil. Cien Saude Colet 2014; 19(5):1613-1622.^,1010. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18.^,1111. Sotero AM, Cabral PC, Silva GAP. Socioeconomic, cultural and demographic maternal factors associated with dietary patterns of infants. Rev. paul. pediatr. 2015; 33(4):445-452.^,1717. Neumann AICP, Shirassu MM, Fisberg RM. Consumo de alimentos de risco e proteção para doenças cardiovasculares entre funcionários públicos. Rev. Nutr. 2006; 19(1):19-28.^,1919. Oliveira LPM, Pinheiro SMC, Assis AMO, Silva MCM, Santana MLP, Santos NS, Pinheiro SMC, Barreto ML, Souza CO. Fatores associados a excesso de peso e concentração de gordura abdominal em adultos na cidade de Salvador, Bahia, Brasil. Cad Saude Publica 2009; 25(3):570-582.

20. Esteves EA, Rodrigues CAA, Paulino EJ. Ingestão dietética de cálcio e adiposidade em mulheres adultas. Rev Nutr 2010; 23(4):543-552.

21. Silva EFR, Lewi DS, Vedovato GM, Garcia VRS, Tenore SB, Bassichetto KC. Estado nutricional, clínico e padrão alimentar de pessoas vivendo com HIV/Aids em assistência ambulatorial no município de São Paulo. Rev. bras. epidemiol. 2010; 13(4):677-688.^-2222. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545.^,2424. Pinho CPS, Diniz AS, Arruda Ilma KG, Lira PIC, Cabral PC, Siqueira LAS, Batista Filho M. Consumo de alimentos protetores e preditores do risco cardiovascular em adultos do estado de Pernambuco. Rev Nutr 2012; 25(3):341-351.^,2525. Pinho PM, Machado LM, Torres RS, Carmin SE, Mendes WA, Silva AC, Araújo MS, Ramos EMLS. Síndrome metabólica e sua relação com escores de risco cardiovascular em adultos com doenças crônicas não transmissíveis. Rev. Soc. Bras. Clín. Méd. 2014; 12(1):22-30. and “healthy” populations (n = 12;85.7%)⁸8. Azevedo ECC, Dias FMRS, Diniz AS, Cabral PC. Consumo alimentar de risco e proteção para as doenças crônicas não transmissíveis e sua associação com a gordura corporal: um estudo com funcionários da área de saúde de uma universidade pública de Recife (PE), Brasil. Cien Saude Colet 2014; 19(5):1613-1622.

9. Newby PK, Tucker KL. Empirically derived eating patterns using factor or cluster analysis: a review. Nutr Rev 2004; 62(5):177-203.

10. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18.

11. Sotero AM, Cabral PC, Silva GAP. Socioeconomic, cultural and demographic maternal factors associated with dietary patterns of infants. Rev. paul. pediatr. 2015; 33(4):445-452.^-1212. Neto ACB, Andrade MIS, Lima VLM, Diniz ASD. Peso corporal e escores de consumo alimentar em adolescentes no nordeste brasileiro. Rev. paul. pediatr.2015; 33(3):318-325.^,1717. Neumann AICP, Shirassu MM, Fisberg RM. Consumo de alimentos de risco e proteção para doenças cardiovasculares entre funcionários públicos. Rev. Nutr. 2006; 19(1):19-28.^,1919. Oliveira LPM, Pinheiro SMC, Assis AMO, Silva MCM, Santana MLP, Santos NS, Pinheiro SMC, Barreto ML, Souza CO. Fatores associados a excesso de peso e concentração de gordura abdominal em adultos na cidade de Salvador, Bahia, Brasil. Cad Saude Publica 2009; 25(3):570-582.^,2020. Esteves EA, Rodrigues CAA, Paulino EJ. Ingestão dietética de cálcio e adiposidade em mulheres adultas. Rev Nutr 2010; 23(4):543-552.^,2222. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545.

23. Saldiva SRDM, Silvia LFF, Saldiva PHN. Avaliação antropométrica e consumo alimentar em crianças menores de cinco anos residentes em um município da região do semiárido nordestino com cobertura parcial do programa bolsa família. Rev Nutr 2010; 23(2):221-229.^-2424. Pinho CPS, Diniz AS, Arruda Ilma KG, Lira PIC, Cabral PC, Siqueira LAS, Batista Filho M. Consumo de alimentos protetores e preditores do risco cardiovascular em adultos do estado de Pernambuco. Rev Nutr 2012; 25(3):341-351.^,2626. Mondini L, Levy RB, Saldiva SRDM, Venâncio SI, Stefanini MLR. Prevalência de sobrepeso e fatores associados em crianças ingressantes no ensino fundamental em um município da região metropolitana de São Paulo, Brasil. Cad Saude Publica 2007; 23(8):1825-1834.. In addition to describing and/or evaluating food consumption pattern scores, the studies’ objectives were to relate those scores to nutritional status and sociodemographic, biochemical, cultural, lifestyle, clinical and economic variables.

Only 3 studies (21.4%)⁸8. Azevedo ECC, Dias FMRS, Diniz AS, Cabral PC. Consumo alimentar de risco e proteção para as doenças crônicas não transmissíveis e sua associação com a gordura corporal: um estudo com funcionários da área de saúde de uma universidade pública de Recife (PE), Brasil. Cien Saude Colet 2014; 19(5):1613-1622.^,2222. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545.^,2424. Pinho CPS, Diniz AS, Arruda Ilma KG, Lira PIC, Cabral PC, Siqueira LAS, Batista Filho M. Consumo de alimentos protetores e preditores do risco cardiovascular em adultos do estado de Pernambuco. Rev Nutr 2012; 25(3):341-351. examined anthropometric, sociodemographic and economic variables simultaneously. The sociodemographic and economic variables most frequently evaluated were age (n = 5, 35.7%), sex, schooling and income (n = 4, 28.5%). Most of the studies (n = 8, 57.1%) related food consumption to anthropometric variables.

The anthropometric variables most used were body mass index (BMI) and waist circumference (WC). In all articles where anthropometric data were used (n = 8; 57.1%), weight and height were measured in order to obtain BMI. WC was examined in 6 studies (42.8%)⁸8. Azevedo ECC, Dias FMRS, Diniz AS, Cabral PC. Consumo alimentar de risco e proteção para as doenças crônicas não transmissíveis e sua associação com a gordura corporal: um estudo com funcionários da área de saúde de uma universidade pública de Recife (PE), Brasil. Cien Saude Colet 2014; 19(5):1613-1622.^,1919. Oliveira LPM, Pinheiro SMC, Assis AMO, Silva MCM, Santana MLP, Santos NS, Pinheiro SMC, Barreto ML, Souza CO. Fatores associados a excesso de peso e concentração de gordura abdominal em adultos na cidade de Salvador, Bahia, Brasil. Cad Saude Publica 2009; 25(3):570-582.^,2020. Esteves EA, Rodrigues CAA, Paulino EJ. Ingestão dietética de cálcio e adiposidade em mulheres adultas. Rev Nutr 2010; 23(4):543-552.^,2222. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545.^,2424. Pinho CPS, Diniz AS, Arruda Ilma KG, Lira PIC, Cabral PC, Siqueira LAS, Batista Filho M. Consumo de alimentos protetores e preditores do risco cardiovascular em adultos do estado de Pernambuco. Rev Nutr 2012; 25(3):341-351.^,2525. Pinho PM, Machado LM, Torres RS, Carmin SE, Mendes WA, Silva AC, Araújo MS, Ramos EMLS. Síndrome metabólica e sua relação com escores de risco cardiovascular em adultos com doenças crônicas não transmissíveis. Rev. Soc. Bras. Clín. Méd. 2014; 12(1):22-30..

Regarding the studies’ prior assumptions (as the method provides for this), different food pattern distributions were observed, as well as different food group names, as appropriate to the objectives of each study (Chart 1). In half the studies, foods were classified into 2 groups (n = 7; 50%)⁸8. Azevedo ECC, Dias FMRS, Diniz AS, Cabral PC. Consumo alimentar de risco e proteção para as doenças crônicas não transmissíveis e sua associação com a gordura corporal: um estudo com funcionários da área de saúde de uma universidade pública de Recife (PE), Brasil. Cien Saude Colet 2014; 19(5):1613-1622.^,1010. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18.^,1212. Neto ACB, Andrade MIS, Lima VLM, Diniz ASD. Peso corporal e escores de consumo alimentar em adolescentes no nordeste brasileiro. Rev. paul. pediatr.2015; 33(3):318-325.^,1717. Neumann AICP, Shirassu MM, Fisberg RM. Consumo de alimentos de risco e proteção para doenças cardiovasculares entre funcionários públicos. Rev. Nutr. 2006; 19(1):19-28.^,2121. Silva EFR, Lewi DS, Vedovato GM, Garcia VRS, Tenore SB, Bassichetto KC. Estado nutricional, clínico e padrão alimentar de pessoas vivendo com HIV/Aids em assistência ambulatorial no município de São Paulo. Rev. bras. epidemiol. 2010; 13(4):677-688.^,2525. Pinho PM, Machado LM, Torres RS, Carmin SE, Mendes WA, Silva AC, Araújo MS, Ramos EMLS. Síndrome metabólica e sua relação com escores de risco cardiovascular em adultos com doenças crônicas não transmissíveis. Rev. Soc. Bras. Clín. Méd. 2014; 12(1):22-30.^,2626. Mondini L, Levy RB, Saldiva SRDM, Venâncio SI, Stefanini MLR. Prevalência de sobrepeso e fatores associados em crianças ingressantes no ensino fundamental em um município da região metropolitana de São Paulo, Brasil. Cad Saude Publica 2007; 23(8):1825-1834. denominated “risk” and “protective” for CVDs (n = 6; 42.8%)¹⁰10. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18.^,1212. Neto ACB, Andrade MIS, Lima VLM, Diniz ASD. Peso corporal e escores de consumo alimentar em adolescentes no nordeste brasileiro. Rev. paul. pediatr.2015; 33(3):318-325.^,1717. Neumann AICP, Shirassu MM, Fisberg RM. Consumo de alimentos de risco e proteção para doenças cardiovasculares entre funcionários públicos. Rev. Nutr. 2006; 19(1):19-28.^,2121. Silva EFR, Lewi DS, Vedovato GM, Garcia VRS, Tenore SB, Bassichetto KC. Estado nutricional, clínico e padrão alimentar de pessoas vivendo com HIV/Aids em assistência ambulatorial no município de São Paulo. Rev. bras. epidemiol. 2010; 13(4):677-688.^,2424. Pinho CPS, Diniz AS, Arruda Ilma KG, Lira PIC, Cabral PC, Siqueira LAS, Batista Filho M. Consumo de alimentos protetores e preditores do risco cardiovascular em adultos do estado de Pernambuco. Rev Nutr 2012; 25(3):341-351.^,2525. Pinho PM, Machado LM, Torres RS, Carmin SE, Mendes WA, Silva AC, Araújo MS, Ramos EMLS. Síndrome metabólica e sua relação com escores de risco cardiovascular em adultos com doenças crônicas não transmissíveis. Rev. Soc. Bras. Clín. Méd. 2014; 12(1):22-30., for CNCDs (n = 1; 7.1%)⁸8. Azevedo ECC, Dias FMRS, Diniz AS, Cabral PC. Consumo alimentar de risco e proteção para as doenças crônicas não transmissíveis e sua associação com a gordura corporal: um estudo com funcionários da área de saúde de uma universidade pública de Recife (PE), Brasil. Cien Saude Colet 2014; 19(5):1613-1622. and as “healthy” and “unhealthy” (n = 1; 7.1%)²⁶26. Mondini L, Levy RB, Saldiva SRDM, Venâncio SI, Stefanini MLR. Prevalência de sobrepeso e fatores associados em crianças ingressantes no ensino fundamental em um município da região metropolitana de São Paulo, Brasil. Cad Saude Publica 2007; 23(8):1825-1834.. In 21.4% (n = 3)¹⁹19. Oliveira LPM, Pinheiro SMC, Assis AMO, Silva MCM, Santana MLP, Santos NS, Pinheiro SMC, Barreto ML, Souza CO. Fatores associados a excesso de peso e concentração de gordura abdominal em adultos na cidade de Salvador, Bahia, Brasil. Cad Saude Publica 2009; 25(3):570-582.^,2020. Esteves EA, Rodrigues CAA, Paulino EJ. Ingestão dietética de cálcio e adiposidade em mulheres adultas. Rev Nutr 2010; 23(4):543-552.^,2323. Saldiva SRDM, Silvia LFF, Saldiva PHN. Avaliação antropométrica e consumo alimentar em crianças menores de cinco anos residentes em um município da região do semiárido nordestino com cobertura parcial do programa bolsa família. Rev Nutr 2010; 23(2):221-229., the foods were divided into 3 groups under different denominations. Gimeno et al.²²22. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545. divided foods into 4 groups (obesogenic, healthy, mixed and popular); and Sotero et al. ¹¹11. Sotero AM, Cabral PC, Silva GAP. Socioeconomic, cultural and demographic maternal factors associated with dietary patterns of infants. Rev. paul. pediatr. 2015; 33(4):445-452., into 6 groups, by nutrient source of sugar, fat and oil and one group of processed products. Moraes et al.¹⁸18. Moraes SA, Rosas JB, Mondini L, Freitas ICM. Prevalência de sobrepeso e obesidade e fatores associados em escolares de área urbana de Chilpancingo, Guerrero, México, 2004. Cad Saude Publica 2006; 22(6):1289-1301. preferred to use only 1 group (risk foods for chronic disease).

The analytical pathways taken varied greatly: authors used the summation of weights (Sp) as such²¹21. Silva EFR, Lewi DS, Vedovato GM, Garcia VRS, Tenore SB, Bassichetto KC. Estado nutricional, clínico e padrão alimentar de pessoas vivendo com HIV/Aids em assistência ambulatorial no município de São Paulo. Rev. bras. epidemiol. 2010; 13(4):677-688.^,2323. Saldiva SRDM, Silvia LFF, Saldiva PHN. Avaliação antropométrica e consumo alimentar em crianças menores de cinco anos residentes em um município da região do semiárido nordestino com cobertura parcial do programa bolsa família. Rev Nutr 2010; 23(2):221-229., ordered these Sp in terciles¹⁸18. Moraes SA, Rosas JB, Mondini L, Freitas ICM. Prevalência de sobrepeso e obesidade e fatores associados em escolares de área urbana de Chilpancingo, Guerrero, México, 2004. Cad Saude Publica 2006; 22(6):1289-1301.^,1919. Oliveira LPM, Pinheiro SMC, Assis AMO, Silva MCM, Santana MLP, Santos NS, Pinheiro SMC, Barreto ML, Souza CO. Fatores associados a excesso de peso e concentração de gordura abdominal em adultos na cidade de Salvador, Bahia, Brasil. Cad Saude Publica 2009; 25(3):570-582.^,2626. Mondini L, Levy RB, Saldiva SRDM, Venâncio SI, Stefanini MLR. Prevalência de sobrepeso e fatores associados em crianças ingressantes no ensino fundamental em um município da região metropolitana de São Paulo, Brasil. Cad Saude Publica 2007; 23(8):1825-1834., quintiles¹⁰10. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18. and percentiles²²22. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545., Sp by medians and subsequently by interquartile ranges⁸8. Azevedo ECC, Dias FMRS, Diniz AS, Cabral PC. Consumo alimentar de risco e proteção para as doenças crônicas não transmissíveis e sua associação com a gordura corporal: um estudo com funcionários da área de saúde de uma universidade pública de Recife (PE), Brasil. Cien Saude Colet 2014; 19(5):1613-1622.^,1111. Sotero AM, Cabral PC, Silva GAP. Socioeconomic, cultural and demographic maternal factors associated with dietary patterns of infants. Rev. paul. pediatr. 2015; 33(4):445-452.^,1212. Neto ACB, Andrade MIS, Lima VLM, Diniz ASD. Peso corporal e escores de consumo alimentar em adolescentes no nordeste brasileiro. Rev. paul. pediatr.2015; 33(3):318-325.^,2424. Pinho CPS, Diniz AS, Arruda Ilma KG, Lira PIC, Cabral PC, Siqueira LAS, Batista Filho M. Consumo de alimentos protetores e preditores do risco cardiovascular em adultos do estado de Pernambuco. Rev Nutr 2012; 25(3):341-351.; Sp by medians and means and standard deviations²⁰20. Esteves EA, Rodrigues CAA, Paulino EJ. Ingestão dietética de cálcio e adiposidade em mulheres adultas. Rev Nutr 2010; 23(4):543-552. ; and Sp by means and standard deviations¹⁷17. Neumann AICP, Shirassu MM, Fisberg RM. Consumo de alimentos de risco e proteção para doenças cardiovasculares entre funcionários públicos. Rev. Nutr. 2006; 19(1):19-28.^,2525. Pinho PM, Machado LM, Torres RS, Carmin SE, Mendes WA, Silva AC, Araújo MS, Ramos EMLS. Síndrome metabólica e sua relação com escores de risco cardiovascular em adultos com doenças crônicas não transmissíveis. Rev. Soc. Bras. Clín. Méd. 2014; 12(1):22-30..

By applying the scores method, the studies revealed greater consumption of “protective/healthy/cardio-protective’’ foods among obese individuals⁸8. Azevedo ECC, Dias FMRS, Diniz AS, Cabral PC. Consumo alimentar de risco e proteção para as doenças crônicas não transmissíveis e sua associação com a gordura corporal: um estudo com funcionários da área de saúde de uma universidade pública de Recife (PE), Brasil. Cien Saude Colet 2014; 19(5):1613-1622.^,2222. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545., children with higher family income and with mothers with higher levels of schooling¹¹11. Sotero AM, Cabral PC, Silva GAP. Socioeconomic, cultural and demographic maternal factors associated with dietary patterns of infants. Rev. paul. pediatr. 2015; 33(4):445-452. and among individuals with metabolic syndrome²⁵25. Pinho PM, Machado LM, Torres RS, Carmin SE, Mendes WA, Silva AC, Araújo MS, Ramos EMLS. Síndrome metabólica e sua relação com escores de risco cardiovascular em adultos com doenças crônicas não transmissíveis. Rev. Soc. Bras. Clín. Méd. 2014; 12(1):22-30.. Meanwhile, greater consumption of foods that are “non-protective or risk for CVDs” was found in individuals on ART²¹21. Silva EFR, Lewi DS, Vedovato GM, Garcia VRS, Tenore SB, Bassichetto KC. Estado nutricional, clínico e padrão alimentar de pessoas vivendo com HIV/Aids em assistência ambulatorial no município de São Paulo. Rev. bras. epidemiol. 2010; 13(4):677-688., in child beneficiaries of the Bolsa Família family allowance programme²³23. Saldiva SRDM, Silvia LFF, Saldiva PHN. Avaliação antropométrica e consumo alimentar em crianças menores de cinco anos residentes em um município da região do semiárido nordestino com cobertura parcial do programa bolsa família. Rev Nutr 2010; 23(2):221-229., in children whose mothers had higher levels of schooling¹²12. Neto ACB, Andrade MIS, Lima VLM, Diniz ASD. Peso corporal e escores de consumo alimentar em adolescentes no nordeste brasileiro. Rev. paul. pediatr.2015; 33(3):318-325. and in those whose mothers had lower levels of schooling and family income¹¹11. Sotero AM, Cabral PC, Silva GAP. Socioeconomic, cultural and demographic maternal factors associated with dietary patterns of infants. Rev. paul. pediatr. 2015; 33(4):445-452..

In addition, as the method enables associations or correlations to be made with study variables, positive correlations were observed between risk foods for CVDs and biochemical variables (serum lipids¹⁰10. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18.^,2222. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545., impaired glucose tolerance²²22. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545.), anthropometric variables (overweight)¹⁸18. Moraes SA, Rosas JB, Mondini L, Freitas ICM. Prevalência de sobrepeso e obesidade e fatores associados em escolares de área urbana de Chilpancingo, Guerrero, México, 2004. Cad Saude Publica 2006; 22(6):1289-1301.^,2222. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545. and sociodemographic variables (urban background²⁴24. Pinho CPS, Diniz AS, Arruda Ilma KG, Lira PIC, Cabral PC, Siqueira LAS, Batista Filho M. Consumo de alimentos protetores e preditores do risco cardiovascular em adultos do estado de Pernambuco. Rev Nutr 2012; 25(3):341-351. and lower age group)²²22. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545..

Discussion

Scores method

Not only is the scores method for assessing food consumption patterns used to examine diets as cardiovascular risk practices¹⁰10. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18.^,1212. Neto ACB, Andrade MIS, Lima VLM, Diniz ASD. Peso corporal e escores de consumo alimentar em adolescentes no nordeste brasileiro. Rev. paul. pediatr.2015; 33(3):318-325.^,1717. Neumann AICP, Shirassu MM, Fisberg RM. Consumo de alimentos de risco e proteção para doenças cardiovasculares entre funcionários públicos. Rev. Nutr. 2006; 19(1):19-28.^,2121. Silva EFR, Lewi DS, Vedovato GM, Garcia VRS, Tenore SB, Bassichetto KC. Estado nutricional, clínico e padrão alimentar de pessoas vivendo com HIV/Aids em assistência ambulatorial no município de São Paulo. Rev. bras. epidemiol. 2010; 13(4):677-688.^,2424. Pinho CPS, Diniz AS, Arruda Ilma KG, Lira PIC, Cabral PC, Siqueira LAS, Batista Filho M. Consumo de alimentos protetores e preditores do risco cardiovascular em adultos do estado de Pernambuco. Rev Nutr 2012; 25(3):341-351.^,2525. Pinho PM, Machado LM, Torres RS, Carmin SE, Mendes WA, Silva AC, Araújo MS, Ramos EMLS. Síndrome metabólica e sua relação com escores de risco cardiovascular em adultos com doenças crônicas não transmissíveis. Rev. Soc. Bras. Clín. Méd. 2014; 12(1):22-30. (it originated in the study of diets as potentially atherogenic and cardiovascular risk practices)¹⁰10. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18., but also offers the opportunity to group foods by a pattern that is to be investigated, as shown by the diversity of different possibilities found in the studies reviewed. In addition to characterising food patterns, the scores method has the advantage of permitting statistical analyses to evaluate diet quality, because it makes it possible to establish associations with explanatory variables relating to eating habits.

The WHO suggests that populations’ food consumption would be better represented and assessed by food patterns⁵5. World Health Organization (WHO). Report of a Joint FAO/WHO Consultation. Preparation and Use of Food-Based Dietary Guidelines. Geneva: WHO; 1998., considering that individuals do not consume either nutrients or foods in isolation²⁷27. Perozzo G, Olinto MTA, Dias-da-costa JS, Henn RL, Sarriera J, Pattussi MP. Associação dos padrões alimentares com obesidade geral e abdominal em mulheres residentes no Sul do Brasil. Cad Saude Publica 2008; 24(10):2427-2439.. In that light, there is growing interest in this line of investigation into consumption of groups of foods considered to define healthy and unhealthy food patterns²⁸28. Brasil. Ministério da Saúde (MS). Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. Brasília: MS; 2011..

Food patterns are known to differ widely among different populations and are thus difficult to generalise about, as they result from complex interactions among multidimensional characteristics, including environmental, demographic, social, economic and cultural factors²²22. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545.. Studies intending to discuss this complexity in the light of the relation between diet and health outcomes have come to focus on identifying food patterns¹1. McNaughton SA, Mishra GD, Brunner EJ. Food patterns associated with blood lipids are predictive of coronary heart disease: the Whitehall II study. Br J Nutr 2009; 102(4):619-624.^,2929. Kourlaba G, Panagiotakos DB, Mihas K, Alevizos A, Marayiannis K, Mariolis A, Tountas Y. Dietary patterns in relation to socio-economic and lifestyle characteristics among Greek adolescents: a multivariate analysis. Public Health Nutr 2008; 12(9):1366-1372.^,3030. Pou SA, del Pilar Díaz M, De La Quintana AG, Forte CA, Aballay LR. Identification of dietary patterns in urban population of Argentina: study on diet-obesity relation in population-based prevalence study. Nutr Res Pract 2016; 10(6):616-622..

The association between food patterns and CNCD-related factors has been the object of a number of studies⁸8. Azevedo ECC, Dias FMRS, Diniz AS, Cabral PC. Consumo alimentar de risco e proteção para as doenças crônicas não transmissíveis e sua associação com a gordura corporal: um estudo com funcionários da área de saúde de uma universidade pública de Recife (PE), Brasil. Cien Saude Colet 2014; 19(5):1613-1622.^,1010. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18.

11. Sotero AM, Cabral PC, Silva GAP. Socioeconomic, cultural and demographic maternal factors associated with dietary patterns of infants. Rev. paul. pediatr. 2015; 33(4):445-452.^-1212. Neto ACB, Andrade MIS, Lima VLM, Diniz ASD. Peso corporal e escores de consumo alimentar em adolescentes no nordeste brasileiro. Rev. paul. pediatr.2015; 33(3):318-325.^,1717. Neumann AICP, Shirassu MM, Fisberg RM. Consumo de alimentos de risco e proteção para doenças cardiovasculares entre funcionários públicos. Rev. Nutr. 2006; 19(1):19-28.

18. Moraes SA, Rosas JB, Mondini L, Freitas ICM. Prevalência de sobrepeso e obesidade e fatores associados em escolares de área urbana de Chilpancingo, Guerrero, México, 2004. Cad Saude Publica 2006; 22(6):1289-1301.

19. Oliveira LPM, Pinheiro SMC, Assis AMO, Silva MCM, Santana MLP, Santos NS, Pinheiro SMC, Barreto ML, Souza CO. Fatores associados a excesso de peso e concentração de gordura abdominal em adultos na cidade de Salvador, Bahia, Brasil. Cad Saude Publica 2009; 25(3):570-582.

20. Esteves EA, Rodrigues CAA, Paulino EJ. Ingestão dietética de cálcio e adiposidade em mulheres adultas. Rev Nutr 2010; 23(4):543-552.

21. Silva EFR, Lewi DS, Vedovato GM, Garcia VRS, Tenore SB, Bassichetto KC. Estado nutricional, clínico e padrão alimentar de pessoas vivendo com HIV/Aids em assistência ambulatorial no município de São Paulo. Rev. bras. epidemiol. 2010; 13(4):677-688.

22. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545.

23. Saldiva SRDM, Silvia LFF, Saldiva PHN. Avaliação antropométrica e consumo alimentar em crianças menores de cinco anos residentes em um município da região do semiárido nordestino com cobertura parcial do programa bolsa família. Rev Nutr 2010; 23(2):221-229.

24. Pinho CPS, Diniz AS, Arruda Ilma KG, Lira PIC, Cabral PC, Siqueira LAS, Batista Filho M. Consumo de alimentos protetores e preditores do risco cardiovascular em adultos do estado de Pernambuco. Rev Nutr 2012; 25(3):341-351.

25. Pinho PM, Machado LM, Torres RS, Carmin SE, Mendes WA, Silva AC, Araújo MS, Ramos EMLS. Síndrome metabólica e sua relação com escores de risco cardiovascular em adultos com doenças crônicas não transmissíveis. Rev. Soc. Bras. Clín. Méd. 2014; 12(1):22-30.^-2626. Mondini L, Levy RB, Saldiva SRDM, Venâncio SI, Stefanini MLR. Prevalência de sobrepeso e fatores associados em crianças ingressantes no ensino fundamental em um município da região metropolitana de São Paulo, Brasil. Cad Saude Publica 2007; 23(8):1825-1834. . Many point to a positive association between inappropriate food pattern and factors such as overweight and obesity, high levels of glucose, total cholesterol, HDL and LDL cholesterol, triglycerides and others³¹31. Casado L, Vianna LM, Thuler, LCM. Fatores de Riscos para Doenças crônicas não Transmissíveis no Brasil: uma revisão sistemática. Rev. bras. cancerol. 2009; 55(4):379-388..

The analyses of demographic, socioeconomic, anthropometric and clinical variables presented in the studies justify saying that this is an aspect considered an important influence on food consumption.

Food pattern and demographic and socioeconomic variables

A positive correlation was observed between risk foods for CVDs and sociodemographic variables (urban background²⁴24. Pinho CPS, Diniz AS, Arruda Ilma KG, Lira PIC, Cabral PC, Siqueira LAS, Batista Filho M. Consumo de alimentos protetores e preditores do risco cardiovascular em adultos do estado de Pernambuco. Rev Nutr 2012; 25(3):341-351. and lower age group²²22. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545.). Of particular note was that the development of new lifestyles in urban areas, the distances between home and workplace, the relative ease with which processed food products are purchased, the influence of the media on diet, and the popularisation of information were conjunctural determinants of the supply, consumption and availability of risk foods for CVDs³²32. Neumann AICP, Martins IS, Marcopito LF, Araujo EAC. Padrões alimentares associados a fatores de risco para doenças cardiovasculares entre residentes de um município brasileiro. Rev Panam Salud Publica. 2007; 22(5):329-339..

As regards associations between socioeconomic variables and food consumption, the food groups comprising processed foods and those associated with cardiovascular risk were found to associate with individuals with low income¹⁷17. Neumann AICP, Shirassu MM, Fisberg RM. Consumo de alimentos de risco e proteção para doenças cardiovasculares entre funcionários públicos. Rev. Nutr. 2006; 19(1):19-28. and whose mothers had less schooling¹¹11. Sotero AM, Cabral PC, Silva GAP. Socioeconomic, cultural and demographic maternal factors associated with dietary patterns of infants. Rev. paul. pediatr. 2015; 33(4):445-452., a finding that diverges from Lioret et al.³³33. Lioret S, McNaughton SA, Crawford D, Spence AC, Hesketh K, Campbell KJ. Parents’ dietary patterns are significantly correlated: findings from the Melbourne Infant Feeding Activity and Nutrition Trial Program. Br J Nutr 2012; 108(3):518-526., who observed that individuals whose mothers had less schooling consumed more of the fruits and vegetables group.

Levy et al.⁴4. Levy RB, Claro RM, Mondini L, Sichieri R, Monteiro C A. Regional and socioeconomic distribution of household food availability in Brazil, in 2008-2009. Rev Saude Publica 2012; 46(1):6-15., studying the regional and socioeconomic distribution of household availability of foods in Brazil from secondary data in the 2008-2009 family budget survey (Pesquisa de Orçamentos Familiares, POF), observed that the participation by food groups comprising milk and dairy products, fruit, vegetables and legumes, animal fat, alcoholic beverages and ready meals tended to increase uniformly with rising family income level, while food groups comprising beans and other pulses, cereals and cereal products and roots and tubers displayed the inverse trend. They also found that consumption of table sugar decreased and consumption of soft drinks increased with rising income, while consumption of beef and processed meats increased and consumption of other types of meat decreased or held stable.

Studies indicate that social determinants, including lack of schooling, low income, married and widowed marital status, aging and others, are preponderant in the genesis of obesity³⁴34. Gallus S, Lugo A, Murisic B, Bosetti C, Boffetta P, La Vecchia C. Overweight and obesity in 16 European countries. Eur J Nutr 2015; 54(5):679-689.

35. Wang Y, Beydoun MA. The obesity epidemic in the United States--gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev. 2007; 29:6-28.^-3636. Aballay LR, Osella AR, De La Quintana AG, Diaz MDP. Nutritional profile and obesity: results from a random-sample population-based study in Córdoba, Argentina. Eur J Nutr 2016; 55(2):675-685.. The relationship between social determinants and obesity is complex and still not totally clear. It is hypothesised that obesity can result as a sequela of early protein-energy malnutrition, from imbalance between energy expenditure and calorie intake or be connected with genetic factors³⁷37. Malta DC, Santos MAS, Andrade SSCA, Oliveira TP, Stopa SR, Oliveira MM, Jaime P. Tendência temporal dos indicadores de excesso de peso em adultos nas capitais brasileiras, 2006-2013. Cien Saude Colet 2016; 21(4):1061-1069.^,3838. Pinheiro ARO, Freitas SFT, Corso ACT. Uma abordagem epidemiológica da obesidade. Rev. Nutr. 2004; 17(4):523-533..

Food pattern and anthropometric nutritional status

CNCD-risk and obesogenic food patterns were observed to associate with overweight²²22. Gimeno SGA, Mondini L, Moraes AS, Freitas ICM. Padrões de consumo de alimentos e fatores associados em adultos de Ribeirão Preto, São Paulo, Brasil: Projeto OBEDIARP. Cad Saude Publica 2011; 27(3):533-545.^,2626. Mondini L, Levy RB, Saldiva SRDM, Venâncio SI, Stefanini MLR. Prevalência de sobrepeso e fatores associados em crianças ingressantes no ensino fundamental em um município da região metropolitana de São Paulo, Brasil. Cad Saude Publica 2007; 23(8):1825-1834. and central obesity²⁶26. Mondini L, Levy RB, Saldiva SRDM, Venâncio SI, Stefanini MLR. Prevalência de sobrepeso e fatores associados em crianças ingressantes no ensino fundamental em um município da região metropolitana de São Paulo, Brasil. Cad Saude Publica 2007; 23(8):1825-1834.. Diets that are high calorie density, rich in fats (particularly those of animal origin) and low in food fibre content can explain a substantial portion of cases of some chronic diseases, such as obesity, CVDs, diabetes mellitus and metabolic syndrome¹⁷17. Neumann AICP, Shirassu MM, Fisberg RM. Consumo de alimentos de risco e proteção para doenças cardiovasculares entre funcionários públicos. Rev. Nutr. 2006; 19(1):19-28.^,3939. Lenz A, Olinto MTA, Dias-da-Costa JS, Alves AL, Balbinotti M, Pattussi MP, Bassani DG. Socioeconomic, demographic and lifestyle factors associated with dietary patterns of women living in Southern Brazil. Cad Saude Publica 2009; 25(6):1297-306..

Also, data from the 2008-2009 family budget survey revealed that in Brazil, in the population over 20 years of age, prevalence of overweight, in that period was 50.0% in men and 48.0% in women⁴⁰40. Instituto brasileiro de geografia e estatística (IBGE). Pesquisa de Orçamentos Familiares 2008-2009: Antropometria e estado nutricional de crianças, adolescentes e adultos no Brasil. Rio de Janeiro: IBGE; 2010.. That fact is connected with the new lifestyle pattern in Brazilian society, characterised by the presence of unhealthy diets and sedentarism. This is confirmed by the food consumption assessment data in the family budget survey, which reveals various adverse features in the Brazilian population’s diet⁴4. Levy RB, Claro RM, Mondini L, Sichieri R, Monteiro C A. Regional and socioeconomic distribution of household food availability in Brazil, in 2008-2009. Rev Saude Publica 2012; 46(1):6-15..

Food pattern and risk factors for CVDs/CNCDs

In this regard, the studies that were reviewed evaluated associations of food consumption patterns with lifestyle, biochemical profile, clinical profile and age as a risk factor.

As regards lifestyle, an “obesogenic” pattern was observed only in active individuals, which could result from a lifestyle in the process of changing. Meanwhile, the habit of spending hours watching television and eating meals in front of the television – which is emerging as an important factor risk for CNCDs⁴¹41. Rezende LFM, Rodrigues Lopes M, Rey-López JP, Matsudo VKR, Luiz OC. Sedentary behavior and health outcomes: an overview of systematic reviews. PLoS ONE 2014; 9(8):e105620.^,4242. Bickham DS, Blood EA, Walls CE, Shrier LA, Rich M. Characteristics of screen media use associated with higher BMI in young adolescents. J. Pediatr 2013; 131(5):935-941., especially among children and adolescents⁴³43. Oliveira JS, Barufaldi LA, Abreu GA, Leal VS, Brunken GS, Vasconcelos SML, Santos MM, Bloch KV. ERICA: uso de telas e consumo de refeições e petiscos por adolescentes brasileiros. Rev Saude Publica 2016; 50(1):7s., because it is accompanied by unsuitable food patterns (ready meals, fast food and the like) – was observed in one of the articles of this review¹¹11. Sotero AM, Cabral PC, Silva GAP. Socioeconomic, cultural and demographic maternal factors associated with dietary patterns of infants. Rev. paul. pediatr. 2015; 33(4):445-452.. Studies that investigate early onset of obesity underline the importance of the influence of the family environment on the risk of a child becoming obese. Family attitudes to the purchase and presentation of foods, to eating and physical activity habits and the support offered to promote leisure activities can influence children’s food and physical activity patterns⁴⁴44. Scaglioni S, Salvioni M, Galimberti C. Influence of parental attitudes in the development of children eating behaviour. Br J Nutr 2008; 99(1):22-25.^,4545. Ovaskainen ML, Nevalainen J, Uusitalo L, Tuokkola JJ, Arkkola T, Kronberg-Kippilä C, Veijola R, Knip M, Virtanen SM.. Some similarities in dietary clusters of pre-school children and their mothers. Br J Nutr 2009; 102(3):443-452..

The diet-related atherogenicity found by Fornés et al.¹⁰10. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18. corroborated the well-known, traditional, cause-and-effect relationship, because serum cholesterol levels are influenced by the amount of cholesterol – and particularly the quantity of saturated and trans fat – in the diet. People who consume larger amounts of animal fats are have higher levels of serum cholesterol and display greater incidence of coronary atherosclerosis⁴⁶46. Santos RD, Gagliardi ACM, Xavier HT, Magnoni CD, Cassani R, Lottenberg AMP, Filho CA, Araújo DB, Cesena FY, Alves RJ, Fenelon G, Nishioka SAD, Faludi AA., Geloneze B, Scherr C, Kovacs C, Tomazzela C, Carla C, Barrera-Arellano D, Cintra D, Quintão E, Nakandakare E., Fonseca FAH., Pimentel I, Santos JE, Bertolami MC, Rogero M, Izar MC, Nakasato M, Damasceno NRT, Maranhão R, Cassani RSL, Perim R, Ramos S. I Diretriz sobre o consumo de gorduras e saúde cardiovascular. Arq. Bras. Cardiol. 2013; 100:1-40., independently of country, culture and ethnicity.

Olindo et al.⁴⁷47. Olinto MTA, Gigante DP, Horta B, Silveira V, Oliveira I, Willett W. Major dietary patterns and cardiovascular risk factors among young Brazilian adults. Eur J Nutr 2012; 51(3):281-291. found a positive association between a “processed” food pattern (hot dog, cheeseburger, beer, beef, processed meats, savouries, soft drinks, pizza, barbecue, potato chips and savoury snacks) and biochemical markers for cardiovascular risk (low HDL, and high cholesterol and LDL).

From the clinical standpoint, in one study, individuals undergoing ART, generally accompanied by lipodystrophy (and thus having CNCDs), displayed food pattern consumption characterised by foods that were not protective against CVDs. Moraes et al.¹⁸18. Moraes SA, Rosas JB, Mondini L, Freitas ICM. Prevalência de sobrepeso e obesidade e fatores associados em escolares de área urbana de Chilpancingo, Guerrero, México, 2004. Cad Saude Publica 2006; 22(6):1289-1301., meanwhile, observed consumption of such foods increasing in frequency with advancing age.

Eyken et al.⁴⁸48. Eyken EBBDV, Moraes CL. Prevalence of risk factors for cardiovascular diseases in an urban male population in Southeast Brazil. Cad Saude Publica 2009; 25(1):111-123. found that, the older the age group, the higher the proportion of sedentary individuals and the greater the use of cigarettes. They stressed that, at more advanced age, there is a much stronger likelihood of increasing risk factors for CVDs/CNCDs, which demands constant assessment of related factors. These data evidence the importance of studies, with representative samples, designed to specify food patterns and their associations with risk or protective factors for CVDs and CNCDs.

Other means of defining food patterns

The DASH (Dietary Approaches to Stop Hypertension) study conducted in 1995 by Sacks et al.⁴⁹49. Sacks FM, Obarzanek E, Windhauser MM, Svetkey LP, Vollmer WM, McCullough M, Karanja N, Lin PH, Steele P, Proschan MA, Marguerite A, Evans RD, Lawrence JA, George A, Thomas MV, Moore TG. Rationale and design of the Dietary Approaches to Stop Hypertension trial (DASH). A multicenter controlled-feeding study of dietary patterns to lower blood pressure. Annals of Epidemiol 1995; 5(2):108-118. revealed that a dietary pattern rich in fruit, vegetables, legumes and grains, milk and skimmed milk products, fish, poultry and lean meats, and poor in sweets and sugar-rich beverages, reduces blood pressure even in healthy individuals⁵⁰50. Chiu S, Bergeron N, Williams PT, Bray GA, Sutherland B, Krauss RM. Comparison of the DASH (Dietary Approaches to Stop Hypertension) diet and a higher-fat DASH diet on blood pressure and lipids and lipoproteins: a randomized controlled trial. Am J Clin Nutr 2016; 103(2):341-347.. Paula et al.⁵¹51. Paula TP, Steemburgo T, Almeida JC, Dall’alba V, Gross JL, Azevedo MJ. The role of Dietary Approaches to Stop Hypertension (DASH) diet food groups in blood pressure in type 2 diabetes. Br J Nutr 2012; 108(1):155-162. adopted such a food pattern in type-II diabetics and observed reduced blood pressure levels, as compared with individuals with type-II diabetics without that type of diet.

The Nurse’s Health Study identified two food patterns in women from 38 to 63 years old: the “prudent” food pattern (comprising fruit, vegetables, legumes, fish and grains) was found among women who smoked less, used more vitamin supplements, consumed more fibres and proteins and less saturated fats; on the other hand, women who consumed the “western” pattern (comprising red and processed meats, confectionary, desserts and refined grains) displayed less sound health-related habits⁵²52. Willett WC. Nutritional epidemiology issues in chronic disease at the turn of the century. Epidemiol Rev 2000; 22(1):82-86..

In Brazil, one of the first studies to identify food patterns a posteriori on the basis of data from the national household sample survey (Pesquisa Nacional de Amostragem Domiciliar, 1995) was conducted by Sichieri⁵³53. Sichieri R. Dietary patterns and their associations with obesity in the Brazilian city of Rio de Janeiro. Obes Res 2002; 10(1):42-48.. The study of found two food patterns: a “traditional” one comprising predominantly foods that are typical of Brazilian culture, such as rice and beans, and another, “western” pattern, characterised by the consumption of industrialised foods. They also observed an inverse association between the “traditional” pattern and increasing BMI, indicating that this pattern is protective against obesity⁵²52. Willett WC. Nutritional epidemiology issues in chronic disease at the turn of the century. Epidemiol Rev 2000; 22(1):82-86..

In 2012, Weber et al.⁵⁴54. Weber B, Galante AP, Bersch-Ferreira AC, Torreglosa CR, Carvalho VO, Victor ES, Espírito-Santo JA, Ross-Fernandes MB, Soares RM, Costa RP, Lara ES, Buehler AM, Berwanger O. Effects of Brazilian Cardioprotective Diet Program on risk factors in patients with coronary heart disease: a Brazilian Cardioprotective Diet randomized pilot trial. Clinics (São Paulo) 2012; 67(12):1407-1414. published the findings of a pilot study of a cardio-protective Brazilian diet (DICA-Br) conducted at the Hospital do Coração (HCOR) in São Paulo for application in a multicentre study. One of the purposes of the study was to adapt the Mediterranean diet to a Brazilian pattern, while encouraging consumption of regional foods accessible to a large part of Brazil’s population. The clinical trial was conducted with individuals in secondary prevention of CVDs, who were monitored for 12 weeks. Those in the DICA-Br group were benefited by greater reductions in blood pressure, glycaemia and BMI than those who received general guidance in line with the Brazilian directives for CVDs. Those findings were attributed mainly to the inclusion of foods that are protective against CVDs and widely available in Brazil, showing that it is possible and necessary to adapt the “Mediterranean” food pattern and that this has a positive impact on individuals at high risk of coronary disease.

Also in Brazil, Marchioni et al.⁵⁵55. Marchioni DM, Claro RM, Levy RB, Monteiro CA. Patterns of food acquisition in Brazilian households and associated factors: a population-based survey. Public Health Nutr 2011; 14(9):1586-1592. examined data from the 2002-03 family budget survey and identified two patterns, a “dual pattern” – which comprised foods recognised as being beneficial to health, such as fruit, vegetables and yoghurt, but also contained a contribution from foods with adverse health effects, such as sweets and desserts, processed meats, ready meals – and, on the other hand, a “traditional pattern” comprising foods normally used in home preparations, such as rice, beans, eggs, roots and tubers. In their results, they highlighted the existence of a dual type of food pattern, i.e., of healthy and unhealthy foods, very like consumption patterns already observed in other studies and associated with higher risk of CVDs⁵⁴54. Weber B, Galante AP, Bersch-Ferreira AC, Torreglosa CR, Carvalho VO, Victor ES, Espírito-Santo JA, Ross-Fernandes MB, Soares RM, Costa RP, Lara ES, Buehler AM, Berwanger O. Effects of Brazilian Cardioprotective Diet Program on risk factors in patients with coronary heart disease: a Brazilian Cardioprotective Diet randomized pilot trial. Clinics (São Paulo) 2012; 67(12):1407-1414..

A meta-analysis of controlled, randomised prospective studies demonstrated the relation between high adherence to a Mediterranean food pattern (based on consumption of fresh foods, such as legumes, fruit, and olive oil) and lower risk of CVDs and metabolic syndrome⁵⁶56. Grosso G, Marventano S, Yang J, Micek A, Pajak A, Scalfi L, Galvano F, Kales SN. A Comprehensive Meta-analysis on Evidence of Mediterranean Diet and Cardiovascular Disease: Are Individual Components Equal? Crit Rev Food Sci Nutr 2015; 57(15):3218-3232.^,5757. Godos J, Zappalà G, Bernardini S, Giambini I, Bes-Rastrollo M, Martinez-Gonzalez M. Adherence to the Mediterranean diet is inversely associated with metabolic syndrome occurrence: a meta-analysis of observational studies. Int J Food Sci Nutr 2016; 68(2):138-148..

From the foregoing, it can be seen that a number of epidemiological studies have used food patterns to evaluate risk of chronic diseases and variation in biomarkers related to overall diet exposure¹⁷17. Neumann AICP, Shirassu MM, Fisberg RM. Consumo de alimentos de risco e proteção para doenças cardiovasculares entre funcionários públicos. Rev. Nutr. 2006; 19(1):19-28.^,2121. Silva EFR, Lewi DS, Vedovato GM, Garcia VRS, Tenore SB, Bassichetto KC. Estado nutricional, clínico e padrão alimentar de pessoas vivendo com HIV/Aids em assistência ambulatorial no município de São Paulo. Rev. bras. epidemiol. 2010; 13(4):677-688.^,5858. Fung TT, McCullough ML, Newby PK, Manson JE, Meigs JB, Rifai N, Willett WC, Hu FB. Diet-quality scores and plasma concentrations of markers of inflammation and endothelial dysfunction. Am J Clin Nutr 2005; 82(1):163-173.. This has followed from the assumption that evaluating the effect of isolated nutrients is not equivalent to evaluating the effect of a food item with a variety of nutrients or of foods consumed as part of a habitual food pattern containing various different foods⁵⁹59. Hu FB. Dietary pattern analysis: a new direction in nutritional epidemiology. Curr. opin. lipidol. 2002; 13(1):3-9..

Identifying populations’ foods patterns is an important study objective of nutritional epidemiology, with a view to understanding the factors responsible for health⁶⁰60. Assis AM, Barreto ML. Epidemiologia Nutricional. In: Almeida Filho N, Barreto ML, organizadores. Epidemiologia & saúde. Rio de Janeiro: Guanabara Koogan; 2011. p. 213-214.. Meanwhile, there is a need to refine how food patterns are evaluated by way of new methodologies. That is, use of the scores method to evaluate food consumption frequency can be a useful instrument in assessing the quality of food consumed by individuals.

This is the first systematic review to examine studies that have used the scores method proposed by Fornés et al. to evaluate food consumption. This strategy of applying scores offers the advantage of maximising the utilisation of information on food consumption. Understanding patterns of food consumption and nutrient intake and their associations with human health is important to dietary guidance, particularly for developing countries, which are increasingly adopting western food patterns⁶¹61. Auestad N, Hurley JS, Fulgoni VL, Schweitzer CM. Contribution of Food Groups to Energy and Nutrient Intakes in Five Developed Countries. Nutrients 2015; 7(6):4593-618..

Limitations of the studies

The main limitation identified by the reviewers was the lack of standardisation in specifying food consumption patterns, which made it difficult to compare findings of among studies. However, the range of analytical options that the method offers gives researchers the freedom to apply it as best suits their research object, which constitutes an incomparable advantage.

Conclusion

This review of studies applying the scores method led to the conclusion that it constitutes a tool capable of evaluating food consumption and of establishing associations between food patterns and study variables. The review of studies showed that this method enables individual exposure to nutrients or components of the diet or food group investigated to be analysed at different stages of the lifecycle and that anthropometric, biochemical, socioeconomic, demographic and clinical variables were the most studied to establish associations with food consumption.

Acknowledgments

To the following funding institutions Ministério da Saúde/ Departamento de Ciência e Tecnologia (MS-DECIT), Fundação de Amparo à Pesquisa do Estado de Alagoas (FAPEAL), Secretaria de Estado da Saúde de Alagoas (SESAU), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes).

References

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