ABSTRACT:

Introduction:

Nutrition counseling has played a critical role in the prevention and treatment of various diseases.

Objective:

To evaluate how adults and elderly people, who are residents in an urban area of Southern Brazil, received nutritional counseling.

Methods:

This was a cross-sectional population based study. Data was collected through a questionnaire applied at home. The outcome was the prevalence of nutritional counseling received in the past year that came from different means, including means of communication. Sociodemographic variables, doctor visits in the past year, nutritional state and other healthcare variables were analyzed.

Results:

The sample included 1,296 individuals (rate of answer of 90.7%). The results indicate that the majority of the people interviewed were females (56.6%), with their age ranging from 18 to 59 years-old (75.3%). The prevalence of people receiving nutritional counseling was 19.9% (95%CI 17.3 -22.5). It was higher among women than men (p = 0.01). The sex-adjusted analyses showed a statistically significant (p < 0.05) association in men for the variables: schooling ≥ 12 years; medical consultation in the last year; low weight; obesity; diabetes and hypertension. Among the women, the following variables were associated with the outcome: health insurance; medical consultation in the last year; obesity and diabetes.

Conclusions:

The low prevalence of nutritional counseling and its association with diseases exposes the need for it to be implemented not only for treatment purposes but also as preventive health actions.

Keywords:
Nutritional epidemiology; Cross-sectional studies; Prevalence; Counseling; Food habits

INTRODUCTION

Healthy eating is considered to be one of the most important means of promoting health¹1. USDA, DHHS. Dietary guidelines for Americans. 7ª ed. Washington, D.C.: Government Printing Office; 2010.. It contributes to a sense of physical and mental well-being²2. Shepherd J, Harden A, Rees R, Brunton G, Garcia J, Oliver S, et al. Young people and healthy eating: a systematic review of research on barriers and facilitators. Health Educ Res 2006; 21(2): 239-57. https://doi.org/10.1093/her/cyh060
https://doi.org/10.1093/her/cyh060... and is fundamental in the prevention of chronic diseases³3. World Health Organization. Noncommunicable Diseases (NCD) Country Profiles. Genebra: World Health Organization; 2014.. However, in recent years, the nutritional transition resulting from urbanization and industrialization has led to inadequate eating habits and the progressive decrease in physical activity, contributing to the increase in chronic noncommunicable diseases (NCDs)⁴4. Popkin BM. Contemporary nutritional transition: determinants of diet and its impact on body composition. Proc Nutr Soc 2011; 70(1): 82-91. https://doi.org/10.1017/S0029665110003903
https://doi.org/10.1017/S002966511000390... .

Thus, nutritional counseling or guidance - the process by which individuals are aided in selecting and implementing appropriate eating and lifestyle behaviors, and which can be expressed by different social agents, vehicles and formats - becomes an eminent tool for the development of good habits⁵5. Rodrigues EM, Soares FPTP, Boog MCF. Resgate do conceito de aconselhamento no contexto do atendimento nutricional. Rev Nutr 2005; 18(1): 119-28. http://dx.doi.org/10.1590/S1415-52732005000100011
http://dx.doi.org/10.1590/S1415-52732005... . Studies show that while nutritional counseling is an important tool for good health, it is still not used enough⁶6. Anis NA, Lee RE, Ellerbeck EF, Nazir N, Greiner KA, Ahluwalia JS. Direct observation of physician counseling on dietary habits and exercise: patient, physician, and office correlates. Prev Med 2004; 38(2): 198-202. https://doi.org/10.1016/j.ypmed.2003.09.046
https://doi.org/10.1016/j.ypmed.2003.09.... ^,77. Klumbiene J, Petkeviciene J, Vaisvalavicius V, Miseviciene I. Advising overweight persons about diet and physical activity in primary health care: Lithuanian health behaviour monitoring study. BMC Public Health 2006; 6(30): 1-6. https://doi.org/10.1186/1471-2458-6-30
https://doi.org/10.1186/1471-2458-6-30... ^,88. Andrade KA, Toledo MTT, Lopes MS, Carmo GES, Lopes ACS. Aconselhamento sobre modos saudáveis de vida na Atenção Primária e práticas alimentares dos usuários. Rev Esc Enferm USP 2012; 46(5): 1117-24. http://dx.doi.org/10.1590/S0080-62342012000500012
http://dx.doi.org/10.1590/S0080-62342012... ^,99. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... . In addition, the literature associates nutritional guidance with being overweight⁷7. Klumbiene J, Petkeviciene J, Vaisvalavicius V, Miseviciene I. Advising overweight persons about diet and physical activity in primary health care: Lithuanian health behaviour monitoring study. BMC Public Health 2006; 6(30): 1-6. https://doi.org/10.1186/1471-2458-6-30
https://doi.org/10.1186/1471-2458-6-30... ^,99. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... ^,1010. Covi-Crochet A, Cittée JC, Letrilliart L. Frequency, modes, and determinants of patients’ nutritional education in family medicine: the Nutrimege study. Rev Prat 2010; 60(6 Supl.): 4-8.^,1111. Lopes ACS, Toledo MTT, Câmara AMCS, Menzel H-JK, Santos LC. Condições de saúde e aconselhamento sobre alimentação e atividade física na Atenção Primária à Saúde de Belo Horizonte-MG. Epidemiol Serv Saúde 2014; 23(3): 475-86. http://dx.doi.org/10.5123/S1679-49742014000300010
http://dx.doi.org/10.5123/S1679-49742014... or having a chronic disease⁹9. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... ^,1010. Covi-Crochet A, Cittée JC, Letrilliart L. Frequency, modes, and determinants of patients’ nutritional education in family medicine: the Nutrimege study. Rev Prat 2010; 60(6 Supl.): 4-8.^,1212. Nguyen HT, Markides KS, Winkleby MA. Physician advice on exercise and diet in a U.S. sample of obese Mexican-American adults. Am J Health Promot 2011; 25(6): 402-9. https://doi.org/10.4278/ajhp.090918-QUAN-305
https://doi.org/10.4278/ajhp.090918-QUAN... ^,1313. Santos RP, Horta PM, Souza CS, Santos CA, Oliveira HBS, Almeida LMR, et al. Aconselhamento sobre alimentação e atividade física: prática e adesão de usuários da atenção primária. Rev Gaúcha Enferm 2012; 33(4): 14-21. http://dx.doi.org/10.1590/S1983-14472012000400002
http://dx.doi.org/10.1590/S1983-14472012... .

A study conducted in the United States (US) about receiving dietary counseling during primary care physician visits found that good eating habits were discussed in 25% of the consultations⁶6. Anis NA, Lee RE, Ellerbeck EF, Nazir N, Greiner KA, Ahluwalia JS. Direct observation of physician counseling on dietary habits and exercise: patient, physician, and office correlates. Prev Med 2004; 38(2): 198-202. https://doi.org/10.1016/j.ypmed.2003.09.046
https://doi.org/10.1016/j.ypmed.2003.09.... . Regarding the factors associated with receiving nutritional counseling, international studies report that people aged 35 to 59 years old⁷7. Klumbiene J, Petkeviciene J, Vaisvalavicius V, Miseviciene I. Advising overweight persons about diet and physical activity in primary health care: Lithuanian health behaviour monitoring study. BMC Public Health 2006; 6(30): 1-6. https://doi.org/10.1186/1471-2458-6-30
https://doi.org/10.1186/1471-2458-6-30... ^,1010. Covi-Crochet A, Cittée JC, Letrilliart L. Frequency, modes, and determinants of patients’ nutritional education in family medicine: the Nutrimege study. Rev Prat 2010; 60(6 Supl.): 4-8.^,1414. Honda K. Factors underlying variation in receipt of physician advice on diet and exercise: applications of the behavioral model of health care utilization. Am J Health Promot 2004; 18(5): 370-77. https://doi.org/10.4278/0890-1171-18.5.370
https://doi.org/10.4278/0890-1171-18.5.3... , that have a disease¹⁰10. Covi-Crochet A, Cittée JC, Letrilliart L. Frequency, modes, and determinants of patients’ nutritional education in family medicine: the Nutrimege study. Rev Prat 2010; 60(6 Supl.): 4-8.^,1212. Nguyen HT, Markides KS, Winkleby MA. Physician advice on exercise and diet in a U.S. sample of obese Mexican-American adults. Am J Health Promot 2011; 25(6): 402-9. https://doi.org/10.4278/ajhp.090918-QUAN-305
https://doi.org/10.4278/ajhp.090918-QUAN... and are obese⁷7. Klumbiene J, Petkeviciene J, Vaisvalavicius V, Miseviciene I. Advising overweight persons about diet and physical activity in primary health care: Lithuanian health behaviour monitoring study. BMC Public Health 2006; 6(30): 1-6. https://doi.org/10.1186/1471-2458-6-30
https://doi.org/10.1186/1471-2458-6-30... ^,1010. Covi-Crochet A, Cittée JC, Letrilliart L. Frequency, modes, and determinants of patients’ nutritional education in family medicine: the Nutrimege study. Rev Prat 2010; 60(6 Supl.): 4-8.^,1414. Honda K. Factors underlying variation in receipt of physician advice on diet and exercise: applications of the behavioral model of health care utilization. Am J Health Promot 2004; 18(5): 370-77. https://doi.org/10.4278/0890-1171-18.5.370
https://doi.org/10.4278/0890-1171-18.5.3... receive more guidance.

In Brazil, studies on primary care and population-based national studies show a prevalence of nutritional counseling around 40 to 59%⁸8. Andrade KA, Toledo MTT, Lopes MS, Carmo GES, Lopes ACS. Aconselhamento sobre modos saudáveis de vida na Atenção Primária e práticas alimentares dos usuários. Rev Esc Enferm USP 2012; 46(5): 1117-24. http://dx.doi.org/10.1590/S0080-62342012000500012
http://dx.doi.org/10.1590/S0080-62342012... ^,1111. Lopes ACS, Toledo MTT, Câmara AMCS, Menzel H-JK, Santos LC. Condições de saúde e aconselhamento sobre alimentação e atividade física na Atenção Primária à Saúde de Belo Horizonte-MG. Epidemiol Serv Saúde 2014; 23(3): 475-86. http://dx.doi.org/10.5123/S1679-49742014000300010
http://dx.doi.org/10.5123/S1679-49742014... ^,1313. Santos RP, Horta PM, Souza CS, Santos CA, Oliveira HBS, Almeida LMR, et al. Aconselhamento sobre alimentação e atividade física: prática e adesão de usuários da atenção primária. Rev Gaúcha Enferm 2012; 33(4): 14-21. http://dx.doi.org/10.1590/S1983-14472012000400002
http://dx.doi.org/10.1590/S1983-14472012... and 29 to 38%⁹9. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... , respectively. Furthermore, being older⁸8. Andrade KA, Toledo MTT, Lopes MS, Carmo GES, Lopes ACS. Aconselhamento sobre modos saudáveis de vida na Atenção Primária e práticas alimentares dos usuários. Rev Esc Enferm USP 2012; 46(5): 1117-24. http://dx.doi.org/10.1590/S0080-62342012000500012
http://dx.doi.org/10.1590/S0080-62342012... ^,99. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... , female⁸8. Andrade KA, Toledo MTT, Lopes MS, Carmo GES, Lopes ACS. Aconselhamento sobre modos saudáveis de vida na Atenção Primária e práticas alimentares dos usuários. Rev Esc Enferm USP 2012; 46(5): 1117-24. http://dx.doi.org/10.1590/S0080-62342012000500012
http://dx.doi.org/10.1590/S0080-62342012... ^,99. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... , overweight⁹9. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... ^,1111. Lopes ACS, Toledo MTT, Câmara AMCS, Menzel H-JK, Santos LC. Condições de saúde e aconselhamento sobre alimentação e atividade física na Atenção Primária à Saúde de Belo Horizonte-MG. Epidemiol Serv Saúde 2014; 23(3): 475-86. http://dx.doi.org/10.5123/S1679-49742014000300010
http://dx.doi.org/10.5123/S1679-49742014... and having chronic illnesses⁹9. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... ^,1313. Santos RP, Horta PM, Souza CS, Santos CA, Oliveira HBS, Almeida LMR, et al. Aconselhamento sobre alimentação e atividade física: prática e adesão de usuários da atenção primária. Rev Gaúcha Enferm 2012; 33(4): 14-21. http://dx.doi.org/10.1590/S1983-14472012000400002
http://dx.doi.org/10.1590/S1983-14472012... are associated with receiving more counseling.

Although the literature highlights the great importance of healthy eating, as well as other lifestyle habits¹1. USDA, DHHS. Dietary guidelines for Americans. 7ª ed. Washington, D.C.: Government Printing Office; 2010.^,1515. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para a população brasileira. 2ª ed. Brasília: Ministério da Saúde; 2014., there is a shortage of Brazilian studies investigating the prevalence of nutritional counseling. Since nutritional assistance is an important public health strategy for coping with dietary problems¹⁶16. Coutinho JG, Gentil PC, Toral N. A desnutrição e obesidade no Brasil: o enfrentamento com base na agenda única da nutrição. Cad Saúde Pública 2008; 24(Supl. 2): S332-40. http://dx.doi.org/10.1590/S0102-311X2008001400018
http://dx.doi.org/10.1590/S0102-311X2008... , this study aimed to evaluate nutritional counseling received by adults and elderly people living in the urban area of a southern Brazilian municipality in the past year. It also assessed whether socioeconomic factors, having an NCD, nutritional status and exposure to health services may influence recieving nutritional counseling.

METHODOLOGY

This is a population-based cross-sectional study conducted in the urban area of Rio Grande, Rio Grande do Sul. The study on receiving nutritional counseling is part of the project entitled “Saúde da População Riograndina” (Health of the Riograndina Population), which was approved by the Health Research Ethics Committee of the Universidade Federal do Rio Grande, which aimed to study health conditions and associated factors in the adult and elderly population in the urban area of the municipality in 2016.

The following parameters were used to calculate the sample size: an expected prevalence of receiving nutritional counseling of 30%, a confidence level of 95%, 1.5 for the effect of sample design, a margin of error of 3.5 percentage points and 10% for losses and refusals. In these cases, the investigation needed to include at least 1,086 individuals. For the associated factors, in order to work with an alpha error of 0.05, a beta error of 0.20, an unexposed/exposed ratio of 9.0, a prevalence of disease in those exposed of 75.87% and a risk ratio of 1.75, the survey needed to include at least 1,356 individuals. Already included in this value was 1.5 for design effect, 15% for control of potential confounders and 10% for losses and refusals.

For a representative selection of the adult and elderly population of the municipality, the sampling process took place in multiple stages, considering population size, census tracts and households, based on data from the 2010 Population Census¹⁷17. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011.. In the first instance, a systematic selection of census tracts in the urban area was performed, followed by a systematic re-selection of households within each sector, resulting in a final number of 711 households with an expected average of 2.08 individuals per household¹⁷17. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011.. All of the individuals aged ≥ 18 years old in the selected households were considered eligible, except those who were institutionalized in nursing homes, hospitals or prisons at the time of the study, and those with a physical and/or mental disability that prevented them from answering the questionnaire.

Data collection was performed with a single, pre-coded and standardized questionnaire, which was applied by nine selected and trained interviewers between April and July of 2016. The questionnaires were reviewed and coded by the research supervisors and typed up twice in order to reduce any errors. Quality control was performed concurrently with data collection by applying a reduced questionnaire in 10.5% of the sample, with a Kappa index of 0.80¹⁸18. Landis JR, Koch GG. The measurement of observer agremment for categorical data. Biometrics 1977; 33(1): 159-74..

The outcome variable was constructed by asking all respondents whether or not they had received nutritional guidance through the question: “Have you received any guidance on how you should eat from <MONTH> of last year until now?”. This advice could have been given through various means, even communication media. Those who responded positively to this question were asked where and from whom they received this guidance; the type of nutritional guidance they received, which included the response options of “no” or “yes” for: “eat less fatty and fried foods”; “eat less sweets or sugar”; “eat less salt”; “eat more fruits and vegetables”; “other type of advice”. Furthermore, they were asked if they had received any written guidance and if their questions around food had been answered.

The independent variables studied were: sex; age; skin color as reported by the interviewee; marital status; schooling, in years; property index, in tertiles¹⁹19. Filmer D, Pritchett LH. Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India. Demography 2001; 38(1): 115-32. https://doi.org/10.1353/dem.2001.0003
https://doi.org/10.1353/dem.2001.0003... , and considered household characteristics (source of drinking water, number of sleeping arrangments and bathrooms in the house) and some household goods (car, computer, internet, landline, microwave, washing machine, tumble dryer and DVD player); health insurance; medical consultation in the last year; nutritional status obtained by calculating body mass index (BMI) using the weight and height reported by the interviewee; and dyslipidemia, diabetes mellitus and systemic arterial hypertension, obtained by asking about having received a medical diagnosis.

Statistical calculations were performed using Stata^® 11.2 software. Initially, the bivariate analysis was performed with the calculation of the 95% confidence interval (95%CI), the prevalence ratio and p-value. Afterwards, the variables were analyzed using a Poisson regression model, and following a three-level hierarchical model, with only those with p ≤ 0.20 remaining in the model. In the first (most distal), the sociodemographic characteristics included were: age; sex; and skin color. In the second, the variables were: education; goods index; and having health insurance. At the third (more proximal) level, the variables related to health were used: medical consultation in the past year; nutritional status; systemic arterial hypertension; diabetes mellitus; and dyslipidemia.

This study is part of a larger research project entitled “Saúde da população riograndina” (Health of the Riograndina Population), which was approved by the Health Research Ethics Committee (CEPAS) of the Universidade Federal do Rio Grande (FURG), under case number no. 1.473.344 (CAAE: 52939016.0.0000.5324), report no. 20/2016.

RESULTS

The study consisted of 1,429 individuals, with a response rate of 1,296 (90.7%) participants, and had a total of 9.3% losses and refusals. The design effect for the study outcome was 1.35 and the intraclass correlation coefficient was 0.017.

Of the 1,296 respondents, most of them were female (56.6%), aged between 18 and 59 years old (75.3%), white-skinned (82.9%), did not have a partner (53 8%), had between 0 and 11 years of schooling (72.6%), had health insurance (52.6%), had consulted a doctor in the last year (80%) and were overweight or obese (61.6%). Regarding chronic diseases, 28.2% reported having hypertension, 16.3% reported having dyslipidemia (high cholesterol and/or triglycerides) and 7% reported having diabetes.

The prevalence of receiving nutritional counseling in the last year was 19.9% (95%CI 17.3 - 22.5), and was higher among women (22.6%; 95%CI 19.2 - 26.0 ) than among men (16.4%; 95%CI 12.9 - 19.8), p = 0.01.

In the adjusted analysis among men (Table 1), it was observed that those with 12 or more years of schooling received almost 3 times more nutritional counseling than those with up to 8 years of schooling, as well as those who had consulted a doctor in the last year (PR = 2.77; 95%CI 1.34 - 5.70). Regarding nutritional status, both obese and underweight men received more guidance than eutrophic men. However, underweight men received 3 times more counseling (PR = 3.33; 95%CI 1.36 - 8.01). In relation to patients with chronic diseases, diabetic (PR = 2.55; 95%CI 1.62 - 4.01) and hypertensive men (PR = 1.98; 95%CI 1.29 - 3.05) received approximately 2 times more eating guidelines than those who reported not having these diseases

After the adjusted analysis in the group of women (Table 2), it was found that those who had health insurance had a 67% higher prevalence (95%CI 30 - 116) of receiving food counseling than those who did not. Those who had gone to a doctor’s consult in the last year had a prevalence 2.8 (95%CI 1.48 - 5.30) times higher than those who did not go to a consultation. For women with obesity, this rate was 82% (95%CI 16 - 185) higher, as well as for those with diabetes who had 2.29 (95%CI 1.60 - 3.25) times more counseling.

When asked what kind of nutritional advice they received, the most common was advice to consume more fruits and vegetables (89.5%), followed by advice to consume less fatty or fried foods (88.8%), sweets or sugar (85.7%) and salt (81.4%). Of the 258 individuals who received nutritional counseling, 184 (71.3%) received all 4 of these guidelines. Still, 22.1% (n = 57) reported receiving guidance addressing other issues, such as: fractioning meals, drinking more water, consuming less red meat and consuming more whole foods.

Evaluating guidance according to nutritional status, similarity was observed between the groups (Figure 1). Regarding receiving written nutritional counseling, 41.5% said they had not received any counseling, followed by 22.1% who had received a diet and a food list, 15.5% only received a food list, 12.4% received other materials (such as folders or pamphlets) and 8.5% received a diet only.

Evaluating the places where dietary advice was received, 50% of individuals received guidance in a clinic or private practice, 19.4% in public health clinics, 16% in other places such as at work, at home and at the gym, 11.6% in hospitals and 3.1% through the media. As for the professionals who provided these guidelines, doctors came first (50.8%), followed by nutritionists (44.9%). In the perception of more than 92% of respondents, the guidance received was able to clarify the existing doubts about food and 84.1% claimed that it contributed to the improvement of food consumption.

DISCUSSION

In the present study, only 1 in 5 respondents had received any nutritional guidance (19.9%) in the past year. This prevalence was similar to those found in studies conducted in the US and Australia¹⁴14. Honda K. Factors underlying variation in receipt of physician advice on diet and exercise: applications of the behavioral model of health care utilization. Am J Health Promot 2004; 18(5): 370-77. https://doi.org/10.4278/0890-1171-18.5.370
https://doi.org/10.4278/0890-1171-18.5.3... ^,2020. Booth AO, Nowson CA. Patient recall of receiving lifestyle advice for overweight and hypertension from their General Practitioner. BMC Family Practice 2010; 11: 8. https://doi.org/10.1186/1471-2296-11-8
https://doi.org/10.1186/1471-2296-11-8... . National survey data from Health Interview 2000 (US), with 32,374 people, found a 21.3% prevalence of receiving medical dietary advice¹⁴14. Honda K. Factors underlying variation in receipt of physician advice on diet and exercise: applications of the behavioral model of health care utilization. Am J Health Promot 2004; 18(5): 370-77. https://doi.org/10.4278/0890-1171-18.5.370
https://doi.org/10.4278/0890-1171-18.5.3... . Booth and Nowson²⁰20. Booth AO, Nowson CA. Patient recall of receiving lifestyle advice for overweight and hypertension from their General Practitioner. BMC Family Practice 2010; 11: 8. https://doi.org/10.1186/1471-2296-11-8
https://doi.org/10.1186/1471-2296-11-8... interviewed 2,947 residents of South Australia. A total of only 17% said they had received some advice from their doctor regarding diet and/or exercise to lose weight. In other countries, the prevalence of guidance found was higher when compared to this study, as shown by studies conducted in Lithuania (26%) 7 , Poland (40%) 21 and France (42.4%)10.

The value obtained in this research is below that observed in the literature of other Brazilian studies, which range from 29 to 59%⁸8. Andrade KA, Toledo MTT, Lopes MS, Carmo GES, Lopes ACS. Aconselhamento sobre modos saudáveis de vida na Atenção Primária e práticas alimentares dos usuários. Rev Esc Enferm USP 2012; 46(5): 1117-24. http://dx.doi.org/10.1590/S0080-62342012000500012
http://dx.doi.org/10.1590/S0080-62342012... ^,99. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... ^,1111. Lopes ACS, Toledo MTT, Câmara AMCS, Menzel H-JK, Santos LC. Condições de saúde e aconselhamento sobre alimentação e atividade física na Atenção Primária à Saúde de Belo Horizonte-MG. Epidemiol Serv Saúde 2014; 23(3): 475-86. http://dx.doi.org/10.5123/S1679-49742014000300010
http://dx.doi.org/10.5123/S1679-49742014... ^,1313. Santos RP, Horta PM, Souza CS, Santos CA, Oliveira HBS, Almeida LMR, et al. Aconselhamento sobre alimentação e atividade física: prática e adesão de usuários da atenção primária. Rev Gaúcha Enferm 2012; 33(4): 14-21. http://dx.doi.org/10.1590/S1983-14472012000400002
http://dx.doi.org/10.1590/S1983-14472012... . However, it is important to note that of these, only one study was nationally-based⁹9. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... , in which the prevalence of nutritional counseling in the past year ranged from 29 to 38%, according to the type of guidance provided. The others were restricted to samples composed of people who accessed primary health care (PHC)⁸8. Andrade KA, Toledo MTT, Lopes MS, Carmo GES, Lopes ACS. Aconselhamento sobre modos saudáveis de vida na Atenção Primária e práticas alimentares dos usuários. Rev Esc Enferm USP 2012; 46(5): 1117-24. http://dx.doi.org/10.1590/S0080-62342012000500012
http://dx.doi.org/10.1590/S0080-62342012... ^,1111. Lopes ACS, Toledo MTT, Câmara AMCS, Menzel H-JK, Santos LC. Condições de saúde e aconselhamento sobre alimentação e atividade física na Atenção Primária à Saúde de Belo Horizonte-MG. Epidemiol Serv Saúde 2014; 23(3): 475-86. http://dx.doi.org/10.5123/S1679-49742014000300010
http://dx.doi.org/10.5123/S1679-49742014... ^,1313. Santos RP, Horta PM, Souza CS, Santos CA, Oliveira HBS, Almeida LMR, et al. Aconselhamento sobre alimentação e atividade física: prática e adesão de usuários da atenção primária. Rev Gaúcha Enferm 2012; 33(4): 14-21. http://dx.doi.org/10.1590/S1983-14472012000400002
http://dx.doi.org/10.1590/S1983-14472012... .

The prevalence of receiving nutritional counseling was higher among women than among men (22.6 versus 16.4%; p = 0.01), a result also found by other studies⁸8. Andrade KA, Toledo MTT, Lopes MS, Carmo GES, Lopes ACS. Aconselhamento sobre modos saudáveis de vida na Atenção Primária e práticas alimentares dos usuários. Rev Esc Enferm USP 2012; 46(5): 1117-24. http://dx.doi.org/10.1590/S0080-62342012000500012
http://dx.doi.org/10.1590/S0080-62342012... ^,99. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... . This may be related to the fact that women are more concerned with body appearance and health. Thus, they request more nutritional guidance from health professionals than men.

Regarding the factors associated with receiving nutritional guidance, several studies show that greater exposure to medical care can positively influence a patient’s quality of life and change their habits²²22. Hemiö K, Pölönen A, Ahonen K, Kosola M, Viitasalo K, Lindström J. A Simple Tool for Diet Evaluation in Primary Health Care: Validation of a 16-Item Food Intake Questionnaire. Int J Environ Res Public Health 2014; 11(3): 2683-97. https://dx.doi.org/10.3390%2Fijerph110302683
https://dx.doi.org/10.3390%2Fijerph11030... ^,2323. Milder IEJ, Blokstra A, Groot J, Dulmen VS, Bemelmans WJE. Lifestyle counseling in hypertension-related visits-analysis of video-taped general practice visits. BMC Fam Pract 2008; 9: 58. https://doi.org/10.1186/1471-2296-9-58
https://doi.org/10.1186/1471-2296-9-58... . The present study demonstrated that, for both sexes, having consulted the doctor in the past year increased the probability by three of having received nutritional counseling. Through these data, it is possible to emphasize physicians’ role as distributors of nutritional counseling, and the fact that medical consultations are opportunities to offer it.

In both sexes obesity was a significant factor for receiving nutritional guidance. A survey conducted in Lithuania between 2000 and 2004 of 3,000 people aged 20-64 found that only 26% of individuals had been advised to change their diet. However, this study found that the higher the BMI, the greater the likelihood of receiving nutritional counseling⁷7. Klumbiene J, Petkeviciene J, Vaisvalavicius V, Miseviciene I. Advising overweight persons about diet and physical activity in primary health care: Lithuanian health behaviour monitoring study. BMC Public Health 2006; 6(30): 1-6. https://doi.org/10.1186/1471-2458-6-30
https://doi.org/10.1186/1471-2458-6-30... . These results reveal a concern from professionals regarding the inadequate nutritional status of the population, but emphasizes the fact that nutritional guidance is infrequently used as a prevention tool.

As seen in other studies, the presence of NCDs has been associated with a higher likelihood of receiving nutritional counseling⁹9. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... ^,1010. Covi-Crochet A, Cittée JC, Letrilliart L. Frequency, modes, and determinants of patients’ nutritional education in family medicine: the Nutrimege study. Rev Prat 2010; 60(6 Supl.): 4-8.^,1111. Lopes ACS, Toledo MTT, Câmara AMCS, Menzel H-JK, Santos LC. Condições de saúde e aconselhamento sobre alimentação e atividade física na Atenção Primária à Saúde de Belo Horizonte-MG. Epidemiol Serv Saúde 2014; 23(3): 475-86. http://dx.doi.org/10.5123/S1679-49742014000300010
http://dx.doi.org/10.5123/S1679-49742014... ^,1212. Nguyen HT, Markides KS, Winkleby MA. Physician advice on exercise and diet in a U.S. sample of obese Mexican-American adults. Am J Health Promot 2011; 25(6): 402-9. https://doi.org/10.4278/ajhp.090918-QUAN-305
https://doi.org/10.4278/ajhp.090918-QUAN... . In this study, it was observed that men who had diabetes or hypertension, as well as women with diabetes, received about twice as much nutritional counseling as self-reported people without a disease. In Canada, a study of 2,335 patients reporting type II diabetes showed that 47.8% of patients reported receiving at least one type of dietary advice from a health professional in the past year²⁴24. Baillot A, Pelletier C, Dunbar P, Geiss L, Johnson JA, Leiter LA, et al. Profile of adults with type 2 diabetes and uptake of clinical care best practices: results from the 2011 Survey on Living with Chronic Diseases in Canada - Diabetes component. Diabetes Res Clin Pract 2014; 103(1): 11-9. https://doi.org/10.1016/j.diabres.2013.11.022
https://doi.org/10.1016/j.diabres.2013.1... . A US study of diabetic and/or hypertensive individuals found a 53% prevalence of receiving counseling on diet and nutrition services²⁵25. Aparasu RR, Aparasu A. Hypertension management in outpatient visits by diabetic patients. Res Social Adm Pharm 2008; 4(3): 284-29. https://doi.org/10.1016/j.sapharm.2007.07.001
https://doi.org/10.1016/j.sapharm.2007.0... . Brazilian researchers analyzed health conditions, dietary advice and physical activity in PHC and found that 76.2% (p <0.001) of individuals diagnosed with diabetes and 67.9% (p <0.001) of those diagnosed with hypertension received counseling, compared with the groups that did not have these diseases, which had a prevalence of 41.9 and 47.4%, respectively¹¹11. Lopes ACS, Toledo MTT, Câmara AMCS, Menzel H-JK, Santos LC. Condições de saúde e aconselhamento sobre alimentação e atividade física na Atenção Primária à Saúde de Belo Horizonte-MG. Epidemiol Serv Saúde 2014; 23(3): 475-86. http://dx.doi.org/10.5123/S1679-49742014000300010
http://dx.doi.org/10.5123/S1679-49742014... . It seems evident that nutritional counseling has been used as an aid in the treatment of NCDs, which is something positive regarding the importance of healthy eating habits in the prognosis of these diseases.

With regard to the factors that positively influenced having received nutritional guidance, among men it can be observed that those with 12 years or more of schooling were almost 3 times more likely to be counseled. A study of 32,374 individuals ≥ 18 years in the US showed that having a bachelor’s degree or higher was associated with a higher likelihood of receiving dietary advice¹⁴14. Honda K. Factors underlying variation in receipt of physician advice on diet and exercise: applications of the behavioral model of health care utilization. Am J Health Promot 2004; 18(5): 370-77. https://doi.org/10.4278/0890-1171-18.5.370
https://doi.org/10.4278/0890-1171-18.5.3... . In the group of women, having health insurance increased the probability of receiving nutritional counseling by 67%. Also in the US, in a study with 1,787 obese individuals, having health insurance was also significantly associated with receiving counseling (p <0.001)¹²12. Nguyen HT, Markides KS, Winkleby MA. Physician advice on exercise and diet in a U.S. sample of obese Mexican-American adults. Am J Health Promot 2011; 25(6): 402-9. https://doi.org/10.4278/ajhp.090918-QUAN-305
https://doi.org/10.4278/ajhp.090918-QUAN... . The fact that having a higher level of education or having health insurance is associated with a greater chance of receiving nutritional counseling demonstrates the existing inequity regarding exposure to this health measure.

In evaluating the places where guidance was received, half of the individuals received it at a private clinic or office, which may have positively influenced the group of women with health insurance. However, a multi-center study conducted in Brazil found that basic health clinics were the most frequent place to receive nutritional advice⁹9. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... . Lopes et al.¹¹11. Lopes ACS, Toledo MTT, Câmara AMCS, Menzel H-JK, Santos LC. Condições de saúde e aconselhamento sobre alimentação e atividade física na Atenção Primária à Saúde de Belo Horizonte-MG. Epidemiol Serv Saúde 2014; 23(3): 475-86. http://dx.doi.org/10.5123/S1679-49742014000300010
http://dx.doi.org/10.5123/S1679-49742014... point out that PHC is responsible for prevention and health promotion actions, and should therefore guarantee the provision of counseling regardless of the health status of the patients.

When we investigated who was responsible for the counseling, we found that doctors were cited by 50.8%, followed by nutritionists at 44.9%. It is part of the role of nutritionists, as a professional who trains eating habits, to pay attention to the growing changes in the population’s food consumption, acting directly in advocating for the adoption of habits that aim to promote the health and quality of life of individuals²⁶26. Conselho Federal de Nutricionistas. Resolução nº 380/2005. Dispõe sobre a definição das áreas de atuação do nutricionista e suas atribuições, estabelece parâmetros numéricos de referência por ares de atuação e dá outras providências. Brasília: Conselho Federal de Nutricionistas; 2005.. However, health professionals, especially doctors, because they have direct contact with patients, are found to be the main medical professionals responsible for nutritional counseling and a healthy lifestyle⁹9. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... ^,1111. Lopes ACS, Toledo MTT, Câmara AMCS, Menzel H-JK, Santos LC. Condições de saúde e aconselhamento sobre alimentação e atividade física na Atenção Primária à Saúde de Belo Horizonte-MG. Epidemiol Serv Saúde 2014; 23(3): 475-86. http://dx.doi.org/10.5123/S1679-49742014000300010
http://dx.doi.org/10.5123/S1679-49742014... ^,1313. Santos RP, Horta PM, Souza CS, Santos CA, Oliveira HBS, Almeida LMR, et al. Aconselhamento sobre alimentação e atividade física: prática e adesão de usuários da atenção primária. Rev Gaúcha Enferm 2012; 33(4): 14-21. http://dx.doi.org/10.1590/S1983-14472012000400002
http://dx.doi.org/10.1590/S1983-14472012... ^,2222. Hemiö K, Pölönen A, Ahonen K, Kosola M, Viitasalo K, Lindström J. A Simple Tool for Diet Evaluation in Primary Health Care: Validation of a 16-Item Food Intake Questionnaire. Int J Environ Res Public Health 2014; 11(3): 2683-97. https://dx.doi.org/10.3390%2Fijerph110302683
https://dx.doi.org/10.3390%2Fijerph11030... ^,2323. Milder IEJ, Blokstra A, Groot J, Dulmen VS, Bemelmans WJE. Lifestyle counseling in hypertension-related visits-analysis of video-taped general practice visits. BMC Fam Pract 2008; 9: 58. https://doi.org/10.1186/1471-2296-9-58
https://doi.org/10.1186/1471-2296-9-58... . Although nutritionists are the most prepared to give this guidance, unfortunately access to these professionals is still scarce, especially among the lower income population.

It is clear that providing guidance on healthy habits is the responsibility of all health professionals²⁷27. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília: Ministério da Saúde ; 2012.. However, considering that the health clinic was the second most prevalent place to receive guidance, the role of other health professionals, for example nurses and healthcare workers, was scarce. We emphasize the missed opportunities for health prevention and bringing awareness to individuals at times other than during consultations.

Regarding the types of counseling provided, it was observed that almost 90% of the participants reported consuming more fruits and vegetables; less fatty or fried foods; less sweets, sugar and salt after receiving guidance. Silva et al.⁹9. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... , in a study that investigated receiving guidance in the past year, to reduce the intake of salt, sugar and fat, found that the profile of people receiving the different guidelines was very similar. It was more prevalent among women and grew linearly with age, regardless of the type of guidance. Although dietary guidance should not only be understood as the transmission of guidelines related to nutrients, it is extremely important to stimulate greater consumption of fresh foods, and discourage the consumption of ultra-processed foods that are rich in sugar, sodium, trans fats, among other components that, in excess, are harmful to health.

The findings of this study show that, in addition to the low prevalence of nutritional counseling (19.9%), it has been given as a result of an already present disease or when the patient is obese. Doctors and nutritionists are the main sources of information for these patients. It is worth noting that in both sexes, healthy individuals received less guidance, which should not occur.

Nevertheless, some limitations of this study need to be considered. Because it has a cross-sectional design, it leads to reverse causality, which prevents the establishment of cause and effect relationships. A pertinent example is the variable medical consultation in the past year, where it is difficult to say whether having a consultation alone increases the chance of receiving counseling or whether seeking counseling leads to a consultation. Additionally, obtaining health history data and receiving counseling were self-reported, creating the possibility of recall bias, as some participants may have forgotten or omitted data during the interview. Despite the limitations, the results suggest the feasibility of the methodology used, as other studies on nutrition counseling⁸8. Andrade KA, Toledo MTT, Lopes MS, Carmo GES, Lopes ACS. Aconselhamento sobre modos saudáveis de vida na Atenção Primária e práticas alimentares dos usuários. Rev Esc Enferm USP 2012; 46(5): 1117-24. http://dx.doi.org/10.1590/S0080-62342012000500012
http://dx.doi.org/10.1590/S0080-62342012... ^,99. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... ^,1313. Santos RP, Horta PM, Souza CS, Santos CA, Oliveira HBS, Almeida LMR, et al. Aconselhamento sobre alimentação e atividade física: prática e adesão de usuários da atenção primária. Rev Gaúcha Enferm 2012; 33(4): 14-21. http://dx.doi.org/10.1590/S1983-14472012000400002
http://dx.doi.org/10.1590/S1983-14472012... used this method.

It is worth noting that Brazilian studies addressing nutritional counseling are rare, and in a population-based sample,⁹9. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16(4): 995-1004. http://dx.doi.org/10.1590/S1415-790X2013000400019
http://dx.doi.org/10.1590/S1415-790X2013... they are even rarer. Thus, it is important to highlight that the primary data, the sample’s scope, as well as its population representativity and the low non-response rate allow for the results of this research to be less limited to the collection site and to the specific characteristics of the individual.

CONCLUSION

The low prevalence of receiving nutritional counseling, especially among healthy individuals, individuals with low levels of education, those who do not have health insurance, and those who did not have medical consultations in the last year, demonstrates the infrequent use of this practice as a health prevention method that brings awareness to the importance of healthy eating.

ACKNOWLEDGMENTS

To the Coordination for the Improvement of Higher Education Personnel (CAPES), for granting a master’s scholarship to MOS; and to the National Council for Scientific and Technological Development (CNPq), for granting a research productivity scholarship to SCD.

References

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