ABSTRACT

OBJECTIVE

To describe the beverage portion size consumed and to evaluate their association with excess weight in Brazil.

METHODS

We used data from the National Dietary Survey, which included individuals with two days of food record aged over 20 years (n = 24,527 individuals). The beverages were categorized into six groups: soft drink, 100% fruit juice, fruit drink, alcoholic beverage, milk, and coffee or tea. We estimated the average portion consumed for each group and we evaluated, using linear regression, the association between portion size per group and the variables of age, sex, income, and nutritional status. We tested the association between portion size and excess weight using Poisson regression, adjusted for age, sex, income, and total energy intake.

RESULTS

The most frequently consumed beverages in Brazil were coffee and tea, followed by 100% fruit juices, soft drinks, and milk. Alcoholic beverages presented the highest average in the portion size consumed, followed by soft drinks, 100% fruit juice, fruit drink, and milk. Portion size showed positive association with excess weight only in the soft drink (PR = 1.19, 95%CI 1.10–1.27) and alcoholic beverage groups (PR = 1.20, 95%CI, 1.11–1.29), regardless of age, sex, income, and total energy intake.

CONCLUSIONS

Alcoholic beverages and soft drinks presented the highest averages in portion size and positive association with excess weight. Public health interventions should address the issue of portion sizes offered to consumers by discouraging the consumption of large portions, especially sweetened and low nutritional beverages.

Adult; Food Consumption; Beverages; Risk Factors; Overweight, epidemiology; Diet Surveys

INTRODUCTION

Food portion size can be defined as the actual amount of food that is placed on the plate, reflecting the choice of the consumer, restaurant, or food producer, or the amount of food or drink normally eaten or drank at the time of consumption ²2. Benton D . Portion size: what we know and what we need to know . Crit Rev Food Sci Nutr . 2013 ; 55 ( 7 ): 988 - 1004 . https://doi.org/10.1080/10408398.2012.679980
https://doi.org/10.1080/10408398.2012.67... .

Some studies, both in developed countries ¹²12. Nielsen SJ , Popkin BM . Patterns and trends in food portion sizes, 1977-1998 . JAMA . 2003 ; 289 ( 4 ): 450 - 3 . https://doi.org/10.1001/jama.289.4.450
https://doi.org/10.1001/jama.289.4.450... ^,1414. Piernas C , Popkin BM . Increased portion sizes from energy-dense foods affect total energy intake at eating occasions in US children and adolescents: patterns and trends by age group and sociodemographic characteristics, 1977-2006 . Am J Clin Nutr . 2011 ; 94 ( 5 ): 1324 - 32 . https://doi.org/10.3945/ajcn.110.008466
https://doi.org/10.3945/ajcn.110.008466... ^,2020. Steenhuis IHM , Leeuwis FH , Vermeer , WM . Small, medium, large or supersize: trends in food portion sizes in The Netherlands . Public Health Nutr . 2010 ; 13 ( 6 ): 852 - 7 . https://doi.org/10.1017/S1368980009992011
https://doi.org/10.1017/S136898000999201... and in developing countries ¹1. Basu S , Vellakkal S , Agrawal S , Stuckler D , Popkin B , Ebrahim S . Averting obesity and type 2 diabetes in India through sugar-sweetened beverage taxation: an economic- epidemiologic modeling study . PLoS Med . 2014 ; 11 ( 1 ): e1001582 . https://doi.org/10.1371/journal.pmed.1001582
https://doi.org/10.1371/journal.pmed.100... ^,1010. Manyema M , Veerman JL , Chola L , Tugendhaft A , Labadarios D , Hofman K . Decreasing the burden of type 2 diabetes in South Africa: the impact of taxing sugar-sweetened beverages . PLoS One . 2015 ; 10 ( 11 ): e0143050 . https://doi.org/10.1371/journal.pone.0143050
https://doi.org/10.1371/journal.pone.014... ^,2121. Stern D , Piernas C , Barquera S , Rivera JA , Popkin BM . Caloric beverages were major sources of energy among children and adults in Mexico, 1999-2012 . J Nutr . 2014 ; 144 ( 6 ): 949 - 56 . https://doi.org/10.3945/jn.114.190652
https://doi.org/10.3945/jn.114.190652... , have shown an increase in the food portion size consumed, especially in relation to sweetened beverages. This increase in the amount of food consumed coincides with the increase in the prevalence of overweight and obesity in the population of several countries ²³23. Young LR , Nestle M . The contribution of expanding portion sizes to the US obesity epidemic . Am J Public Health . 2002 ; 92 ( 2 ): 246 - 9 . https://doi.org/10.2105/AJPH.92.2.246
https://doi.org/10.2105/AJPH.92.2.246... .

Although excessive weight gain is caused by a complex network of multiple factors, the energy imbalance resulting from excessive energy intake and reduced energy expenditure is the proximal factor that best explains the development of overweight or obesity. The increase in portion sizes has been considered an important factor for this excessive weight gain because of its contribution to greater energy intake ²³23. Young LR , Nestle M . The contribution of expanding portion sizes to the US obesity epidemic . Am J Public Health . 2002 ; 92 ( 2 ): 246 - 9 . https://doi.org/10.2105/AJPH.92.2.246
https://doi.org/10.2105/AJPH.92.2.246... ^,2424. Young LR , Nestle M . Reducing portion sizes to prevent obesity: a call to action . Am J Prev Med . 2012 ; 43 ( 5 ): 565 - 8 . https://doi.org/ 10.1016/j.amepre.2012.07.024
https://doi.org/10.1016/j.amepre.2012.07... . The mechanisms are still not well understood and the recommendations do not reflect the knowledge and complexity of the subject, but the literature suggests that adults substitute or ignore the signs of hunger and satiety when consuming large portions without energy compensation in subsequent meals ²2. Benton D . Portion size: what we know and what we need to know . Crit Rev Food Sci Nutr . 2013 ; 55 ( 7 ): 988 - 1004 . https://doi.org/10.1080/10408398.2012.679980
https://doi.org/10.1080/10408398.2012.67... ^,44. English L , Lasschuijt M , Keller KL . Mechanisms of the portion size effect. What is known and where do we go from here? Appetite . 2015 ; 88 : 39 - 49 . https://doi.org/10.1016/j.appet.2014.11.004
https://doi.org/10.1016/j.appet.2014.11.... .

Despite the evidence that beverage portion size may be related to excessive weight gain, most studies on this subject have been carried out in developed countries, especially in the United States. In Brazil, only one study has evaluated the food portion sizes consumed, in a sample of adults of the city of São Paulo. The authors have found that large food portions from some groups with different energy densities, such as pizza, red meat, rice, snack foods, and soft drinks, are positively associated with excess weight ¹³13. Pereira JL , Mendes A , Crispim S , Marchioni DM , Fisberg RM . Association of overweight with food portion size among adults of São Paulo – Brazil . PLOS One . 2016 : 11 ( 10 ): e0164127 . https://doi.org/10.1371/journal.pone.0164127
https://doi.org/10.1371/journal.pone.016... . However, there are no national studies that have estimated the beverage portion size consumed in a representative sample of the country and its relationship with excess weight.

The limitation of national data on the subject suggests a new focus of research and intervention aimed at subsidizing public health actions for changes in the environment in favor of preventing excess weight and the development of chronic non-communicable diseases related to poor diet. An analysis of the beverage portion size consumed in the country can also aid the evaluation of beverage consumption trends over the years in Brazil. The objective of this study is to describe the beverage portion size consumed and to evaluate its association with excess weight.

METHODS

This is a cross-sectional study based on secondary data from the National Dietary Survey (INA), carried out together with the Household Budget Survey – POF (2008/2009).

The POF (2008/2009) was carried out from May 19, 2008, to May 18, 2009, with national coverage, including urban and rural areas and all income strata. It was conceptualized according to the concept of master sample, which the Brazilian Institute of Geography and Statistics (IBGE) has been adopting for all surveys with domiciliary sample from an Integrated System of Household Surveys, which corresponds to a set of census tracts based on the 2000 Demographic Census.

The tracts included in the master sample were geographically and statistically stratified, which allowed the generation of representative estimates for the Brazilian regions, urban and rural areas, capital, metropolitan region, and different income classes. The sectors tracts that make up the master sample were selected by sampling with probability proportional to the number of households per tract within each stratum.

The sampling plan used in the 2008/2009 POF was the conglomerate in two steps. The first step was the selection of master sample tracts by simple random sampling, amounting to 4,696 sectors. In the second step, the units sampled were the households, selected by simple random sampling within each of the tracts selected, amounting to 55,970 households investigated.

The INA was carried out in a sample of 24% of the households participating in the 2008/2009 POF, in which at least one resident over 10 years of age was interviewed (n = 34,003). For this study, we considered only the individuals who had two days of food record (n = 32,900). Individuals under 20 years of age (n = 7,342), pregnant women, and nursing mothers (n = 1,031) were excluded, amounting to a final sample of 24,527 individuals.

Food consumption data were collected using two food records on non-consecutive days, in which the individuals recorded all food and beverages consumed, the type of preparation, the amount consumed, and the time and place of the meals. Participants received guidance to complete the individual food consumption block from an information booklet containing illustrations of home measures to facilitate the correct filling of the amount of food consumed.

The records were reviewed by interviewers with survey questions if they found fewer than five items consumed over a day, avoiding the underreporting of participants. When no record was observed at intervals longer than three hours, the interviewer confirmed the lack of food intake at that time with the participant.

The amounts of food and beverages consumed in the reports in home measures were transformed into grams or milliliters for the calculation of the amount consumed of each item per informant, based on a table of home measures developed for INA. Details on the quantification of the food and beverages consumed can be found in an official IBGE publication ^aaInstituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares 2008-2009: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; s.d. [cited 2016 Feb 7]. Available from: https://ww2.ibge.gov.br/home/estatistica/populacao/condicaodevida/pof/2008_2009_analise_consumo/default.shtm . For the estimation of the total energy intake of the individuals, we used the table of nutritional composition of the food consumed in Brazil ^bbInstituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares 2008-2009: tabelas de composição nutricional dos alimentos consumidos no Brasil. Rio de Janeiro: IBGE; 2011 [cited 2016 Feb 7].Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv50002.pdf .

During the visitation period, the residents in the household were anthropometrically evaluated (weight and height). A portable electronic scale with 150 kg capacity and 100 g graduation was used to measure weight. In addition, a portable stadiometer with a retractable tape measuring up to 200 cm and a precision of 0.1 cm was used to measure height. The individuals were measured in a flat and well-lit place, without their shoes.

To evaluate the nutritional status of the population, we calculated the body mass index (BMI) from the weight divided by the height squared. The classification of the BMI of the adults followed the parameters of the World Health Organization: low weight (≤ 18.5 kg/m ² ), normal weight (18.5 kg/m ² to 24.9 kg/m ² ), overweight (24.5 kg/m ² to 29.9 kg/m ² ), and obesity (≥ 30 kg/m ² ). Because of the low percentage of individuals with low weight (2%), they were included in the normal weight category.

The data related to the characteristics of the household and residents that we considered in this study were age, sex, and household income per capita .

In order to estimate the household income, we added all the monetary and non-monetary income of the family members, and we obtained the household income per capita by dividing the household income by the number of residents living in it.

To analyze the beverage portions consumed, we considered the two days of food record. First, all beverages mentioned on the survey were grouped into six groups according to nutritional characteristics, type, and portion size: soft drinks, 100% fruit juices, fruit drink, alcoholic beverages, milk, and coffee and tea. Meal replacement drinks were excluded from this analysis.

The amount of beverages prepared from dilution was estimated based on the recommended dilution in the marketed product packaging. For example, the dilution of whole milk powder was calculated as follows: for every 200 ml of milk, two tablespoons of powdered milk (15 g) are recommended, that is, 100 ml of milk ready for consumption is made from 7.5 g of powder. The same transformation was performed for the items of skimmed milk powder, flavored milk powder, and soluble coffee. The other beverages prepared from powder, such as coffee powder and instant coffee, were already diluted into beverage portions in milliliters by the POF ^aaInstituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares 2008-2009: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; s.d. [cited 2016 Feb 7]. Available from: https://ww2.ibge.gov.br/home/estatistica/populacao/condicaodevida/pof/2008_2009_analise_consumo/default.shtm table and did not require further treatment of the datum.

Then, we added the amount of beverages drank per food group at the time of consumption, and we calculated the average portion size consumed per individual from the sum of all the portions consumed by the individual divided by the number of occasions that these items were consumed for each beverage group.

We estimated the percentage of consumers in each beverage group, the median, and the average of the portion consumed of each group. We estimated the median portion of each group based on the entire population, while the average beverage portion size consumed was estimated only among consumers (individuals who recorded consumption of at least one beverage in the group in one of the two days of food record).

We tested the associations between the portion size consumed and the variables of age, sex, income, and nutritional status using linear regression models. The variables age, sex, income, and nutritional status were included in the model as independent variables, and portion size was included as dependent variable. The models to evaluate the relationship between portion size, income, sex, and nutritional status were adjusted for age. All statistical inferences were performed with 5% significance level.

We used Poisson regression models with robust variance to estimate the prevalence ratio (PR) of having excess weight (overweight and obese) according to the portion size consumed in each beverage group. For these analyses, we divided the portion size of each beverage group into three categories, considering non-consumers and the portion size normally marketed and consumed for individual portion: 350 mL (1 can) for soft drinks and alcoholic beverages, 200 mL (1 cup of tea) for coffee or tea, and 240 mL (1 average glass) for 100% fruit juices, fruit drink, and milk. Non-consumers were considered as the reference category. Initially, the models were adjusted for sex and age. Then, we added family income per capita and, finally, total energy intake.

The descriptive analyses were performed in the SAS software, version 9.1.3 (2003, SAS Institute, Cary, NC), and the Poisson regression models were developed in Stata software, version 13.0 (StataCorp. College Station, TX:2013), considering the sample weights of the INA and the effect of the study design.

RESULTS

The study population had average age of 43.2 years, eight years of study, and average family income per capita of R$1,013.5. Half of the population was female (50.9%) and presented excessive weight (overweight and obese).

The most frequently consumed beverages in Brazil were coffee and tea, followed by 100% fruit juices, soft drinks, and milk, while the groups that presented the lowest consumption frequency were fruit drink and alcoholic beverages ( Table 1 ).

Regarding the portion consumed, the beverage group that presented the highest median was alcoholic beverages (525 mL) followed by soft drinks (280 mL). There was no difference between the median value of the 100% fruit juice, fruit drink, and milk groups (240 mL). The lowest median was found for the coffee or tea group (172.5 mL).

The alcoholic beverage group presented the highest average in the portion consumed at the time of consumption (710.8 mL, 95%CI 658.9–762.7), followed by the soft drink (308.2 mL, 95%CI 301.8–314.6), 100% fruit juice (264.5 mL, 95%CI 261.1–267.8), fruit drink (259.8 mL, 95%CI 251.8–267.8), milk (238.7 mL, 95%CI 235.2–242.3), and coffee or tea groups (177.3 mL, 95%CI 173.5–181.0). These averages increased with income only in the soft drink and 100% fruit juice groups ( Table 2 ).

We observed that men reported higher averages of total consumption than women in all beverage groups. Portion size consumed decreased linearly with increasing age in the groups of soft drinks, 100% fruit juice, fruit drink, and milk, in both sexes. Among the male population, the same trend was observed for alcoholic beverages ( Table 3 ). Comparing the age groups, we observed higher consumption of soft drinks, 100% fruit juice, fruit drink, and alcoholic beverages among men aged 20–40 years and older adults (≥ 60 years) and among men aged 40–60 years and older adults. Among women, we observed differences in the 20–40 year old and older adult categories for the soft drink, 100% fruit juice, and fruit drink groups. Women aged 20–40 years also had a higher average in the portion size of soft drink consumption compared to those aged 40–60 years, and those aged 40–60 years had higher averages than female older adults.

The analyses stratified by nutritional status showed that, with increasing BMI levels, portion size increased in the soft drink and alcoholic beverage groups among men, and normal weight men had a higher average in the soft drink portion size compared to obese men. The presence of overweight and obesity among the female population did not influence significant changes in the portion size consumed, except for the coffee or tea group ( Table 4 ).

Only the size of the soft drink and alcoholic beverage portion showed a positive association with excess weight (overweight and obesity) and this relationship was independent of age, sex, income, and total energy intake ( Table 5 ).

DISCUSSION

The findings of this study corroborate the hypothesis that the soft drink and alcoholic beverage portion size is positively associated with excess weight. The identification of the beverage portion size consumed in representative samples of the population is a necessary step to define adequate and country-specific dietary recommendations. This study reinforces the evidence of public health efforts to contain the obesity epidemic, suggesting a new look at behavioral risk factors that may be involved in excessive weight gain and that are modifiable. This is the first study to describe the beverage portion size consumed in Brazil in a representative sample of the country.

In Brazil, the beverage group most frequently consumed by the population was coffee or tea, which presented a smaller portion size at the time of consumption. On the other hand, although alcoholic beverages had the lowest frequency of consumption, they represent the largest portion size at the time of consumption, regardless of age and sex. The average portion size exceeds 700 mL, therefore exceeding the maximum recommended consumption proposed by the Brazilian Society of Cardiology for men (625 mL of beer or 312.5 mL of wine or 93.7 mL of distilled beverage) and women (312.5 mL beer or 156.25 mL of wine or 46.85 mL of distilled beverage) ¹⁹19. Sociedade Brasileira de Cardiologia ; Sociedade Brasileira de Hipertensão ; Sociedade Brasileira de Nefrologia . VI Diretrizes Brasileiras de Hipertensão . Arq Bras Cardiol . 2010 ; 95 ( 1 Supl 1 ): 1 - 51 . https://doi.org/10.1590/S0066-782X2010001700001
https://doi.org/10.1590/S0066-782X201000... .

The consumption of large alcoholic beverage portions not only favors higher energy intake (7 kcal/mL), but it is also associated with increased blood pressure and cardiovascular mortality in general. In addition, the consumption of large doses for long periods of time or acutely is related to cognitive dysfunction and may cause brain damage ¹⁹19. Sociedade Brasileira de Cardiologia ; Sociedade Brasileira de Hipertensão ; Sociedade Brasileira de Nefrologia . VI Diretrizes Brasileiras de Hipertensão . Arq Bras Cardiol . 2010 ; 95 ( 1 Supl 1 ): 1 - 51 . https://doi.org/10.1590/S0066-782X2010001700001
https://doi.org/10.1590/S0066-782X201000... ^,2525. Zorumski CF , Mennerick S , Izumi Y . Acute and chronic effects of ethanol on learning-related synaptic plasticity . Alcohol . 2014 ; 48 ( 1 ): 1 - 17 . https://doi.org/10.1016/j.alcohol.2013.09.045
https://doi.org/10.1016/j.alcohol.2013.0... .

We also highlight that ethanol consumption is much higher in the younger population. The exposure of young persons to health risk behaviors has become the target of scientific research as such behaviors can be incorporated early into the lifestyle of individuals ⁵5. Faria YO , Gandolfi L , Moura LBA . Prevalence of risk behaviors in young university students . Acta Paul Enferm . 2014 ; 27 ( 6 ): 591 - 5 . https://doi.org/10.1590/1982-0194201400096
https://doi.org/10.1590/1982-01942014000... . Data showing the occurrence of health risk behaviors in young adults and their associated factors can help identify groups at risk and monitor the health levels of these individuals, as well as subsidize early intervention strategies to avoid the incorporation of these habits ²⁵25. Zorumski CF , Mennerick S , Izumi Y . Acute and chronic effects of ethanol on learning-related synaptic plasticity . Alcohol . 2014 ; 48 ( 1 ): 1 - 17 . https://doi.org/10.1016/j.alcohol.2013.09.045
https://doi.org/10.1016/j.alcohol.2013.0... .

Fifty-six percent of adults reported 100% fruit juice and soft drink consumption in one of the two days of the survey. Although 100% fruit juice and fruit drink suggest a healthier option compared to soft drinks, they are often consumed with added sugar. Most of the individuals (85%) who reported 100% fruit juice and fruit drink consumption reported using sugar to sweeten the beverages consumed. Another important issue to be considered is the consumption of processed juices which, for the most part, have high amounts of sugar in their composition. However, the relation between 100% fruit juice and fruit drink consumption with excess weight was not significant in this study.

As for soft drinks, although the frequency of consumption was lower than that of 100% fruit juices and fruit drink, the average portion is 17% higher than the juice group when chosen for consumption. In Mexico, this difference is even greater, as the size of portion of soft drinks is five times greater than the portion of 100% fruit juice ²¹21. Stern D , Piernas C , Barquera S , Rivera JA , Popkin BM . Caloric beverages were major sources of energy among children and adults in Mexico, 1999-2012 . J Nutr . 2014 ; 144 ( 6 ): 949 - 56 . https://doi.org/10.3945/jn.114.190652
https://doi.org/10.3945/jn.114.190652... . This data shows the importance of not only the choice of the beverage but also of the amount drank at the time of consumption.

Evidence in developed countries suggests that the average size of the soft drink portion consumed increased from 387.4 mL to 588.5 mL between 1977 and 1998 and to 828 mL in 2004 ³3. Bleich SN , Wang CY , Wang Y , Gortmaker SL . Increasing consumption of sugar-sweetened beverages among US adults: 1988-1994 to 1999-2004 . Am J Clin Nutr . 2009 ; 89 ( 1 ): 372 - 81 . https://doi.org/10.3945/ajcn.2008.26883
https://doi.org/10.3945/ajcn.2008.26883... ^,99. Malik VS , Pan A , Willett WC , Hu FB . Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis Am J Clin Nutr . 2013 ; 98 ( 4 ): 1084 - 102 . https://doi.org/10.3945/ajcn.113.058362
https://doi.org/10.3945/ajcn.113.058362... . Observing the reported trends on domestic availability of soft drinks in the country ⁷7. Levy RB , Claro RM , Mondini L , Sichieri R , Monteiro CA . Distribuição regional e socioeconômica da disponibilidade domiciliar de alimentos no Brasil em 2008-2009 . Rev Saude Publica . 2012 ; 46 ( 1 ): 6 - 15 . https://doi.org/10.1590/S0034-89102011005000088
https://doi.org/10.1590/S0034-8910201100... , we believe that the soft drink portion consumed has also increased over the years in Brazil.

The concern with the consumption of soft drinks and sweetened juices and fruit drink is that the consumption of sweetened beverages is positively associated with the gain of body weight in children and adults. In addition, it is directly related to the increase in triglycerides, visceral adipose tissue, subcutaneous fat, and liver fat. The mechanisms by which these beverages interfere with health remain under discussion. It is believed that the high sugar content in sweetened beverages favors low satiety without compensation in the energy intake in subsequent meals, contributing with excessive weight gain by the increased energy intake ⁹9. Malik VS , Pan A , Willett WC , Hu FB . Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis Am J Clin Nutr . 2013 ; 98 ( 4 ): 1084 - 102 . https://doi.org/10.3945/ajcn.113.058362
https://doi.org/10.3945/ajcn.113.058362... .

Men presented a higher consumption portion in all beverage groups when compared to the portion size consumed by women, corroborating the findings in the American and Mexican population for the consumption of soft drinks and alcoholic beverages ²¹21. Stern D , Piernas C , Barquera S , Rivera JA , Popkin BM . Caloric beverages were major sources of energy among children and adults in Mexico, 1999-2012 . J Nutr . 2014 ; 144 ( 6 ): 949 - 56 . https://doi.org/10.3945/jn.114.190652
https://doi.org/10.3945/jn.114.190652... ^,ccLaComb RP, Sebastian RS, Enns CW, Goldman JD. Beverage choices of U.S. adults: what we eat in America, NHANES 2007–2008. Beltsville: Food Surveys Research Group; 2011 [cited 2016 Feb 7]. (Dietary Data Brief, 6). Available from: https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/DBrief/6_beverage_choices_adults_0708.pdf .

Among men, the effect of age on the reduction in portion size can be observed in all groups except for coffee and tea. Among women, we observed reduced portion size for the soft drink, 100% fruit juice, fruit drink, and milk groups with increasing age; this behavior can be seen as positive given the amount of sugar present in soft drinks, 100% fruit juices, and fruit drink. On the other hand, this fact draws attention to the greater portion of soft drinks consumed by younger adults. As discussed earlier, exposure of young persons to health risk behaviors leads to unhealthy lifestyles and poor eating habits in the future ⁵5. Faria YO , Gandolfi L , Moura LBA . Prevalence of risk behaviors in young university students . Acta Paul Enferm . 2014 ; 27 ( 6 ): 591 - 5 . https://doi.org/10.1590/1982-0194201400096
https://doi.org/10.1590/1982-01942014000... . Regarding milk, although some studies show that its consumption may improve bone integrity ¹⁸18. Sato Y , Iki M , Fugita Y , Tamaki J , Kouda K , Yura , A , et al . Greater milk intake is associated with lower bone turnover, higher bone density, and higher bone microarchitecture index in a population of elderly Japanese men with relatively low dietary calcium intake: Fujiwara-kyo Osteoporosis Risk in Men (FORMEN) Study . Osteoporos Int . 2015 ; 26 ( 5 ): 1585 - 94 . https://doi.org/10.1007/s00198-015-3032-2
https://doi.org/10.1007/s00198-015-3032-... , there is still insufficient evidence that milk consumption protects against fractures, and it may be also associated with higher mortality ⁸8. Ludwig DS , Willett WC . Three daily servings of reduced-fat milk: an evidence-based recommendation? JAMA Pediatr . 2013 ; 167 ( 9 ): 788 - 9 . https://doi.org/10.1001/jamapediatrics.2013.2408
https://doi.org/10.1001/jamapediatrics.2... ^,1111. Michaëlson K , Wolk A , Langenskiöld S , Basu S , Lemming EW , Melhus H , et al . Milk intake and risk of mortality and fractures in women and men: cohort studies . BMJ 2014 ; 349 : g6015 . https://doi.org/10.1136/bmj.g6015
https://doi.org/10.1136/bmj.g6015... .

Considering nutritional status, we observed a linear increase in the portion size consumed for the soft drink and coffee or tea groups with increasing BMI among women and for the soft drink and alcoholic beverage groups among men. The supply of larger food portions leads to increased energy intake and some experimental studies have already shown no calorie compensation in subsequent meals, even after the high energy intake from large food portions. In addition, this effect is maintained for several days ¹⁷17. Rolls BJ . What is the role of portion control in weight management? Int J Obes ( Lond ). 2014 ; 38 Suppl 1 : S1 - 8 . https://doi.org/10.1038/ijo.2014.82
https://doi.org/10.1038/ijo.2014.82... .

This lack of caloric compensation appears to be greater in beverages, especially in those with added sugars, such as soft drinks. In Brazil, an analysis of the INA has found that the consumption of sweetened beverages increased by 158 kcal, 191 kcal, and 180 kcal the energy coming from breakfast, lunch, and dinner, respectively ⁶6. Gombi-Vaca MF , Sichieri R , Verly - Jr E . Caloric compensation for sugar-sweetened beverages in meals: a population-based study in Brazil . Appetite . 2016 ; 98 ( 1 ): 67 - 73 . https://doi.org/10.1016/j.appet.2015.12.014
https://doi.org/10.1016/j.appet.2015.12.... .

In addition, soft drinks and alcoholic beverages can be vehicles of excessive energy consumption as they can lead to an increased intake of other types of food of high energy density and low nutritional density. Alcoholic beverages are also frequently consumed on special occasions, such as parties and barbecues, which last for a long time and lead to the consumption of larger amounts of food. Soft drinks and alcoholic beverages were the only groups that showed a positive association with excess weight in this study. The effect of the soft drink portion on excess weight has also been evidenced in the study by Pereira et al. ¹³13. Pereira JL , Mendes A , Crispim S , Marchioni DM , Fisberg RM . Association of overweight with food portion size among adults of São Paulo – Brazil . PLOS One . 2016 : 11 ( 10 ): e0164127 . https://doi.org/10.1371/journal.pone.0164127
https://doi.org/10.1371/journal.pone.016... in the adult population of the city of São Paulo (OR = 1.016, 95%CI 1.004–1.028), but the authors emphasize that the portion size of other high energy food, such as pizza, red meat, and snacks, also contributes with excessive weight gain.

This study has as a strength the analysis of a little evaluated characteristic of food consumption in national studies, that is, the beverage portion size consumed, which can significantly affect the excessive consumption of calories and contribute with excessive weight gain. In addition, the data refer to a population sample of the country, covering all regions and different socioeconomic levels of Brazil. We highlight the contribution of this study to the formulation of public policies aimed at dietary changes, offering an opportunity for interventions that contribute with a reduction in calorie intake.

Some countries have sought to control the consumption of beverages, focusing on sweetened beverages, using taxation, reduced availability in schools, restrictions on marketing for children, public awareness campaigns, and positive and negative labeling on the packaging; however, little has been done specifically to regulate the size of the portions offered ¹⁶16. Popkin BM , Hawkes C . Sweetening of the global diet, particularly beverages: patterns, trends, and policy responses . Lancet Diabetes Endocrinol . 2016 ; 4 ( 2 ): 174 - 86 . https://doi.org/10.1016/S2213-8587(15)00419-2
https://doi.org/10.1016/S2213-8587(15)00... . In New York, a 2012 regulatory measure limited the sweetened beverage portion size sold in food service and facilities, but law enforcement has encountered barriers ¹⁵15. Pomeranz JL , Brownell K . Can government regulate portion sizes? New Engl J Med . 2014 ; 371 ( 21 ): 1956 - 58 . https://doi.org/10.1056/NEJMp1410076
https://doi.org/10.1056/NEJMp1410076... .

In Brazil, there are no policies aimed at reducing portion size. This study contributes to reinforce the view on an important subject that can favor the reduction in the total caloric intake affecting the maintenance of a healthy weight. However, the results should be viewed with caution, since the estimation of the amount of food consumed is an important source of error in dietary surveys. In this work, the consumption data come from the INA, which had food records as the collection method. Food records are prospective methods, in which individuals record the food and the portion consumed, and it is considered as accurate in the estimation of portion size, avoiding underreporting and memory bias ²²22. Thompson FE , Subar AF . Dietary assessment methodology . In: Coulston AM , Boushey CJ , editors . Nutrition in the prevention and treatment of disease . 2 .ed. London : Elsevier Academic Press ; 2008 . p. 3 - 39 . .

Another limitation of this study is that beverages represent food items often overlooked in dietary surveys. To avoid underreporting, the INA has incorporated the multiple-step method in data collection by asking survey questions on beverage consumption, but the impact of this bias on portion size estimation is unknown. An important issue to be considered is the possible modification in the portion size consumed on weekends. The records of the INA could be randomly made on any day of the week, as long as the days were not consecutive, but most of the records (91.7%) were performed on weekdays. The difference in portion size on weekdays is beyond the scope of this article.

In conclusion, the soft drink and alcoholic beverage portion size showed a positive association with excess weight. Although options considered as healthier, such as 100% fruit juices, are more frequently consumed than soft drinks, the portion size of this latter option is greater when chosen for consumption. Since the increase in portion size may contribute with excessive calorie intake and consequently excess weight, public health interventions should discourage the consumption of large portions, especially for sweetened and low-nutritional beverages. Other studies that address the portion size of other types of food and that consider size differences according to the days of the week are necessary for a better understanding of the eating behavior of individuals regarding the portion sizes consumed and the relationship between portion size and body weight.

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