ABSTRACT

OBJECTIVE:

To assess the evolution of energy and nutrient intake and the prevalence of inadequate micronutrients intakes according to sociodemographic characteristics and Brazilian regions.

METHODS:

The food consumption of 32,749 individuals from the National Dietary Survey of the Household Budget Survey 2008–2009 was analyzed by two food registries, as well as 44,744 subjects from two 24-hour recalls in 2017–2018. Usual intake and percentage of individuals with consumption below the average recommendation for calcium, magnesium, phosphorus, copper and zinc, vitamins A, C, D, E, thiamine, riboflavin, pyridoxine and cobalamin were estimated. Sodium intake was compared to the reference value to reduce the risk of chronic diseases. Analyses were stratified by sex, age group, region and income.

RESULTS:

Mean daily energy intake was 1,753 kcal in 2008–2009 and 1,748 kcal in 2017–2018. The highest prevalence of inadequacy (> 50%) in the two periods were calcium; magnesium; vitamins A, D and E; pyridoxine and, only among adolescents, phosphorus. There was an increase in the prevalence of inadequate vitamin A, riboflavin, cobalamin, magnesium, and zinc among women, and riboflavin among men. The prevalence of inadequacy decreased for thiamine. Sodium intake was excessive in approximately 50% of the population in both periods. The highest variations (about 50%) in the prevalence of inadequacy between the lowest and highest income (< 0.5 minimum wage and > 2 minimum wages per capita) were observed for vitamin B12 and C in both periods. The North and Northeast regions had the highest prevalence of inadequacy.

CONCLUSION:

Both surveys found high prevalence of inadequate nutrient intake and excessive sodium intake. The inadequacy varies according to income strata, increasing in the poorest regions of the country.

DESCRIPTORS:
Food Consumption; Energy Intake; Deficiency Diseases, epidemiology; Diet, Food, and Nutrition; Diet Surveys

INTRODUCTION

The impact of low-quality diets on morbidity and mortality from chronic non-communicable diseases (NCDs) worldwide was greater than that of any other risk factor, including smoking, according to the Global Burden of Disease¹1 Afshin A, Sur PJ, Fay KA, Cornaby L, Ferrara G, Salama JS, et al; GBD 2017 Diet Collaborators. Health effects of dietary risks in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2019;393(10184):1958-72. https://doi.org/10.1016/S0140-6736(19)30041-8
https://doi.org/10.1016/S0140-6736(19)30... . Malnutrition in low- and middle-income countries is often characterized by excess energy intake and micronutrient deficiencies, making it challenging to tackle the double burden of diseases generated by the coexistence of obesity and malnutrition, as well as other non-communicable diseases related to diet²2 Food and Agriculture Organization; International Fund for Agricultural Development; United Nations International Children’s Emergency Fund; World Food Programme; World Health Organization. The State of Food Security and Nutrition in the World, 2020: transforming food systems for affordable healthy diets. Rome (IT): FAO; 2020..

Food security and nutrition are closely linked. Food insecurity is related to poor diet quality, which in turn is linked to manifestations of poor nutrition that increase the risk of malnutrition, overweight, and obesity²2 Food and Agriculture Organization; International Fund for Agricultural Development; United Nations International Children’s Emergency Fund; World Food Programme; World Health Organization. The State of Food Security and Nutrition in the World, 2020: transforming food systems for affordable healthy diets. Rome (IT): FAO; 2020.. In 2015, the countries of the United Nations, including Brazil, committed to the 17 Sustainable Development Goals (SDGs) of the 2030 Agenda. In SDG 2, goal 2.2 is to end all forms of malnutrition³3 United Nations, Department of Economic and Social Affairs. The Millennium Development Goals Report 2015. New York: UN; 2015 [cited 2021 Mar 9]. Available from: https://www.un.org/development/desa/publications/mdg-report-2015.html
https://www.un.org/development/desa/publ... .

In Brazil, in 2019, 26% of the population over 18 years old was obese and about 60% overweight⁴4 Instituto Brasileiro de Geografia e Estatística, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento. Pesquisa Nacional de Saúde, 2019: atenção primária à saúde e informações antropométricas: Brasil. Rio de Janeiro: IBGE; 2020 [cited 2020 Out 29]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101758.pdf
https://biblioteca.ibge.gov.br/visualiza... . Between 2002–2003 and 2019, the proportion of obese in the population aged 20 years and over more than doubled, going from 12.2% to 26.8%⁴4 Instituto Brasileiro de Geografia e Estatística, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento. Pesquisa Nacional de Saúde, 2019: atenção primária à saúde e informações antropométricas: Brasil. Rio de Janeiro: IBGE; 2020 [cited 2020 Out 29]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101758.pdf
https://biblioteca.ibge.gov.br/visualiza... . On the other hand, data from the Household Budget Survey showed that, in 2017–2018, of the 68.9 million households in Brazil, 36.7% (the equivalent of 25.3 million) were with some degree of food insecurity⁵5 Instituto Brasileiro de Geografia e Estatística, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento. Pesquisa de Orçamentos Familiares 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro: IBGE; 2020 [cited 2020 Oct 29]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101749.pdf
https://biblioteca.ibge.gov.br/visualiza... .

The beneficial effects of a healthy eating pattern derive from a cumulative and synergistic effect of nutrients from various food sources⁶6 Segal L, Opie RS. A nutrition strategy to reduce the burden of diet related disease: access to dietician services must complement population health approaches. Front Pharmacol. 2015;6:160. https://doi.org/10.3389/fphar.2015.00160
https://doi.org/10.3389/fphar.2015.00160... . Vitamins and minerals are essential for humans and play an important role in a myriad of metabolic cycles supporting cellular actions. These effects include cardiovascular and bone health, as well as the structure and function of the nervous system⁷7 Bourre JM. Effects of nutrients (in food) on the structure and function of the nervous system: update on dietary requirements for brain. Part 1: micronutrients. J Nutr Health Aging. 2006;10(5):377-85.,⁸8 Tardy AL, Pouteau E, Marquez D, Yilmaz C, Scholey A. Vitamins and minerals for energy, fatigue and cognition: a narrative review of the biochemical and clinical evidence. Nutrients. 2020;12(1):228. https://doi.org/10.3390/nu12010228
https://doi.org/10.3390/nu12010228... .

The analysis of a population’s nutritional status and food consumption can follow several complementary approaches, covering nutrient intakes, food groups, and dietary patterns. The assessment of nutrient intake allows identifying the population groups in which there is a risk of inadequacy, both to plan actions and to analyze public policies already implemented, such as food fortification. Recommendations for nutrient intake aim to ensure that most of the population receives amounts meeting physiological needs⁹9 European Food Safety Authority. Panel on Dietetic Products, Nutrition, and Allergies (NDA). Scientific opinion on principles for deriving and applying Dietary Reference Values. EFSA J. 2010;8(3):1458. https://doi.org/10.2903/j.efsa.2010.1458
https://doi.org/10.2903/j.efsa.2010.1458... .

In the National Dietary Survey (INA) carried out in 2008–2009¹⁰10 Instituto Brasileiro de Geografia e Estatística, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento. Pesquisa de Orçamentos Familiares 2017-2018: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2020 [cited 2020 Oct 29]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101742.pdf
https://biblioteca.ibge.gov.br/visualiza... , the first to collect data on individual food consumption in Brazil, high prevalence of inadequacy were observed for vitamin E, vitamin D, calcium, vitamin A, magnesium, and vitamin C in adolescents, adults, and elderly of both sexes. In view of such result, this study aims to assess the evolution of energy and nutrient intake and the prevalence of inadequate micronutrient intakes among Brazilian adolescents, adults and elderly, according to sociodemographic characteristics and Brazilian regions.

METHODS

Data from two National Dietary Surveys (INA) conducted in 2008–2009 and 2017–2018 were analyzed, as modules of the Household Budget Survey (POF). In both surveys, sampling was defined by clusters, in two stages: in the first, census tracts were drawn; in the second, were drawn households within each sector. Details about the sampling plan are found in other publications¹⁰10 Instituto Brasileiro de Geografia e Estatística, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento. Pesquisa de Orçamentos Familiares 2017-2018: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2020 [cited 2020 Oct 29]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101742.pdf
https://biblioteca.ibge.gov.br/visualiza... ,¹¹11 Instituto Brasileiro de Geografia e Estatística, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento. Pesquisa de Orçamentos Familiares 2008-2009: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2011 [cited 2020 Oct 29]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv50063.pdf
https://biblioteca.ibge.gov.br/visualiza... .

The INA samples corresponded to 24.2% and 34.7% of the households sampled for the POF, totaling 13,569 households and 34,003 individuals in 2008–2009, and 20,112 households and 46,164 individuals in 2017–2018. All individuals aged 10 years or over in the selected households were invited to participate in the individual consumption module. Pregnant and lactating women were not considered in these analyses (n = 1,254 in 2008–2009; n = 1,420 in 2017–2018), totaling 32,749 and 44,744 individuals in the first and second surveys, respectively.

Data Collection and processing

In the 2008–2009 survey, food consumption data were obtained through a food record filled in by the resident on two non-consecutive days (97% responded the second record). Individuals were instructed to record in detail all the foods and beverages consumed, including the way of preparation, ingredients and quantities, preferably in household measures. Still in the households, research agents passed the information on food consumption to a specific program developed by the Brazilian Institute of Geography and Statistics (IBGE)¹¹11 Instituto Brasileiro de Geografia e Estatística, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento. Pesquisa de Orçamentos Familiares 2008-2009: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2011 [cited 2020 Oct 29]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv50063.pdf
https://biblioteca.ibge.gov.br/visualiza... .

In the 2017–2018 survey, collection was performed using 24-hour recalls (R24h) applied on two non-consecutive days, in the same week in which household expenditure data were obtained (84% responded the second R24h). Subjects were asked to report all foods and beverages consumed the day before the two interviews, including a detailed description of the foods (ingredients, additions, preparation) and quantities. Interviews were structured according to the automated multiple-pass method ¹²12 Moshfegh AJ, Rhodes DG, Baer DJ, Murayi T, Clemens JC, Rumpler WV, et al. The US Department of Agriculture Automated Multiple-Pass Method reduces bias in the collection of energy intakes. Am J Clin Nutr. 2008;88(2):324-32. https://doi.org/10.1093/ajcn/88.2.324
https://doi.org/10.1093/ajcn/88.2.324... , using a software specifically designed for the survey for data collection, with 12 options of items that could be added to the food (olive oil, butter, margarine, mayonnaise, cheese, cream milk, sugar, honey, molasses, ketchup, mustard, and soy sauce).

To analyze the amount and nutritional composition of the additions, the type of reported additions was considered. Fat-based additions (olive oil, butter/margarine, mayonnaise, cheese, and sour cream), when reported, could add a maximum of 20% to the consumption, in grams, of the food to which they were added. The additions of sugar, honey, molasses, ketchup, mustard and soy sauce represented a maximum of 10% of the item’s consumption. That is, if ketchup and mustard were added to a sandwich, each addition represents 5% of the sandwich’s weight. Details on data collection, training, quality control and imputation can be found in the IBGE official publication¹⁰10 Instituto Brasileiro de Geografia e Estatística, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento. Pesquisa de Orçamentos Familiares 2017-2018: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2020 [cited 2020 Oct 29]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101742.pdf
https://biblioteca.ibge.gov.br/visualiza... .

Nutritional Composition of Foods

To convert the reported foods into amounts of energy and nutrients, the Brazilian Table of Food Composition (TBCA) v.7.0 was used in both surveys¹³13 Tabela Brasileira de Composição de Alimentos (TBCA). Versão 7.1. São Paulo: Universidade de São Paulo, Food Research Center; 2020 [cited 2020 Oct 29]. Available from: http://www.tbca.net.br
http://www.tbca.net.br... . One should mention, however, the nutritional composition table changed between surveys. The justification for this change is due to the fact the TBCA describes nutritional data on Brazilian foods with the reliability ensured by the International Food Data System Network, of the Food and Agriculture Organization of the United Nations (FAO), which determines guidelines and criteria to be used in the generation, compilation, and use of food composition data¹⁴14 International Network of Food Data Systems. Standards and guidelines. Rome (IT): FAO; 2019 [cited 2020 Oct 29]. Available from: http://www.fao.org/infoods/infoods/standards-guidelines/en/
http://www.fao.org/infoods/infoods/stand... . Thus, to reduce the possibility of divergences in trend assessments and to allow for comparability, the TBCA was used in the energy and nutrient estimates of both surveys.

Statistical Analysis

Usual intake distribution of each nutrient was estimated using the National Cancer Institute (NCI) method, which applies a mixed-effect model after Box-Cox transformation of intake data¹⁵15 Tooze JA, Midthune D, Dodd KW, Freedman LS, Krebs-Smith SM, Subar AF, et al. A new statistical method for estimating the usual intake of episodically consumed foods with application to their distribution. J Am Diet Assoc. 2006;106(10):1575-87. https://doi.org/10.1016/j.jada.2006.07.003
https://doi.org/10.1016/j.jada.2006.07.0... . Parameters (population mean, inter- and within-person variances, effects of the age group and sex variables, income and region, and the lambda of the Box-Cox transformation) are estimated and then used to create usual consumption distributions using Monte Carlo simulation.

Usual intake distributions were estimated for each age-sex group for which there are nutrient recommendation established. Prevalence of inadequacy was estimated using the EAR (estimated average requirement) method as a cutoff point, which represents the percentage of individuals with an intake below the estimated mean value of need for each age-sex group¹⁶16 Institute of Medicine (US), Subcommittee on Interpretation and Uses of Dietary Reference Intakes. Dietary Reference Intake: applications in dietary assessment. Washington, DC: National Academies Press; 2000. https://doi.org/10.17226/9956
https://doi.org/10.17226/9956... .

Sodium intake was compared to the reference value for reducing the risk of chronic diseases (chronic disease risk reduction intakes), as proposed in the latest review of reference values for sodium by the US Institute of Medicine¹⁷17 National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Food and Nutrition Board; Committee to Review the Dietary Reference Intakes for Sodium and Potassium. Dietary reference intakes for sodium and potassium. Washington, DC: National Academies Press; 2019. https://doi.org/10.17226/25353
https://doi.org/10.17226/25353... . From this reference, the percentage of population that should reduce sodium consumption to reduce the risk of chronic diseases is calculated. Considering the incompatibility between the preformed niacin composition in foods, available in the TBCA, with the EAR values expressed in niacin equivalents, prevalence of inadequacy was not calculated for this nutrient.

The prevalence of inadequacy was estimated for each age-sex group for which there are EAR established (9 to 13 years old, 14 to 18, 19 to 30, 31 to 50, 51 to 70, and 70 or more). Then, averages of the prevalence weighted by the expanded sample size of each age group were calculated, stratified into age groups corresponding to the life cycles: adolescents (10–18 years old), adults (19–59 years old), and elderly (60 years or more). The same procedure was used to compute overall prevalence by income strata and region of the country. For the income strata, per capita income of the families was used: less than 0.5, between 0.5 and 1, between 1 and 2, and greater than 2 minimum wages per capita. The minimum wage values on the reference dates of the surveys were: R$ 415.00 (January 15, 2009) and R$ 954.00 (January 15, 2018).

The 95% confidence intervals (95%CI) were calculated for the means and the prevalence of inadequacy using standard error corrected by sample design, estimated by the balanced repeated replication (BRR) technique, used in the NCI method. The 95%CI was used to compare the prevalence of inadequacy between sexes, age groups, income, regions of the country, and the two periods evaluated. Analyses were performed using the SAS software version 9.4.

RESULTS

The mean (95%CI) daily energy intake were similar in the two surveys: 1,753 kcal (1,734–1,772) in 2008–2009 and 1,748 kcal (1,732–1,763) in 2017–2018. Among men, the mean caloric intake in 2008–2009 for adolescents, adults, and the elderly was 1,996 kcal (1,945–2,047), 1,969 kcal (1,940–1,998) and 1,680 kcal (1,633–1,726), respectively; and 1,969 kcal (1,927–2010), 2,018 kcal (1,993–2,044) and 1,708 kcal (1,669–1,747) in 2017–2018. Among women, the values were 1,753 kcal (1,716–1,798), 1,549 kcal (1,539–1,582) and 1,410 kcal (1,370–1,449) in 2008–2009; and 1,674 kcal (1,633–1,715), 1,549 kcal (1,530–1,568) and 1,409 kcal (1,381–1,437) in 2017–2018 for the same age groups, respectively.

A lower energy intake was observed among women and with increasing age in both surveys, with the exception of adult men, whose means did not differ from those of adolescents. However, in both surveys, adult men, when compared to other age groups and women, had the highest average intake for most micronutrients. There was a slight reduction (< 23%) among surveys in average intakes for most micronutrients, while increases in average intakes (4%–10%) occurred only among male adults for thiamine, and among adults of both sexes for vitamin E (Table 1).

Inadequate intakes above 50% of the individuals were observed for pyridoxine, vitamin A, and magnesium in all age groups and, in particular, for phosphorus among adolescents, thiamine among adults and the elderly in both surveys and, in 2017–2018, riboflavin among elderly men and adults of both sexes. Calcium, vitamin D, and vitamin E showed the greatest inadequacies in both surveys (> 85%) (Table 2).

The prevalence of inadequacy for most micronutrients was higher in 2017–2018 than in 2008–2009. The most important differences (> 10%) found in the female population were for riboflavin and zinc in all age groups, and riboflavin between adult and elderly men. Conversely, thiamine among elderly women and men of all ages, and copper among adult and elderly women and among adolescent and adult men were the only nutrients that showed a slight reduction (< 10 percentage points) in the prevalence of inadequacy over the period (Table 2).

In 2008–2009, the percentage of individuals whose sodium intake should be lowered to reduce the risk of chronic disease was, among men, 75% (72%–78%) in adolescents, 71% (70%–72%) in adults, and 52% (47%–56%) in the elderly. Among women, these percentages were 61% (59%–63%), 41% (39%–43%), and 29% (28%–30%), respectively. In 2017–2018, the percentages were, for men, 78% (76%–80%) in adolescents, 74% (73%–75%) in adults, and 52% (50%–54%) in the elderly. Among women, they were 59% (56%–61%), 39% (36%–41%), and 25% (24%–27%), respectively.

Both in 2008–2009 (Tables 3 and 4) and 2017–2018 (Tables 5 and 6), there was a reduction in the prevalence of inadequacy of micronutrients with the increase in average per capita income. In the last survey, except for copper, magnesium, and vitamin D among the elderly, and vitamin E among adolescent women, significant differences were observed between the lowest and highest income levels (< 0.5 vs > 2 minimum wages), being the most expressive (> 15 percentage points) for vitamin C, vitamin A, riboflavin, and thiamine at all ages, phosphorus and pyridoxine among adolescents, and calcium among adult men (Tables 5 and 6).

When the analyses were stratified by regions of the country, similar results were found for men and women, both in 2008–2009 (Tables 7 and 8) and in 2017–2018 (Tables 9 and 10). We found that thiamine, zinc, vitamin C, magnesium, cobalamin, and copper stood out as the most variable micronutrients between regions (Figures 1 and 2). In 2017–2018, the North and Northeast regions, followed by the Midwest, stood out between the first and second positions with the highest prevalence of inadequacy for most of the analyzed nutrients. Among the statistically significant differences, we chose to highlight the most evident ones (> 15 percentage points).

Discrepancies were found in the prevalence of inadequacy of thiamine between the North and Southeast and of zinc between the South and Midwest, whose estimates, in all age groups, were 1.5 to 2 times higher in the first region compared to the last, respectively. The Southeast region stood out with lower prevalence of inadequacy of thiamine in relation to the Northeast and Midwest regions among adults and the elderly, while the South, in the second position of least inadequacy, still differed in relation to the North region among adolescents and adults. In addition, the North region emerged with the highest differences in the prevalence of inadequate vitamin C in contrast to the Southeast region among men and women of all age groups, and magnesium in contrast to the Midwest region for adults, but with a lower prevalence of inadequacy of cobalamin in relation to the South region among adult and elderly women (Tables 9 and 10).

DISCUSSION

Despite the gap of a decade between the two National Dietary Surveys, energy consumption did not vary significantly over the period, and the nutrients that caused concern in the first survey remain those with the highest prevalence of inadequacy in the second survey, with emphasis on calcium, vitamins A, D and E, magnesium, and pyridoxine. The high prevalence of excessive sodium intake in both surveys is also noteworthy, especially among adult men.

The poorest individuals were more vulnerable to inadequate consumption of most of the investigated nutrients, with special attention to vitamins A and C, thiamine, and riboflavin, which had a great absolute and relative difference in comparison with the higher-income stratum. Demographic disparities were observed according to the regions of the country and, in general, the prevalence of inadequate consumption was higher for the North region, followed by the Northeast or Midwest regions.

The prevalence of inadequacy presented here is based on ideal values for the maintenance of biochemical markers in healthy individuals. Therefore, they do not necessarily indicate the appearance of clinical health outcomes. These outcomes result from metabolic mechanisms that involve the interaction between bioavailability and nutrient requirements, as well as individual characteristics related, for example, to genetic factors and nutritional status throughout life¹⁸18 Stover PJ, Garza C, Durga J, Field MS. Emerging concepts in nutrient needs. J Nutr. 2020;150 Suppl 1:2593S-601S. https://doi.org/10.1093/jn/nxaa117
https://doi.org/10.1093/jn/nxaa117... .

Few studies with a representative sample of the Brazilian population analyzed the prevalence of inadequate nutrient intake. Among them, the Study of Cardiovascular Risks in Adolescents (Erica)¹⁹19 Souza AM, Barufaldi LA, Abreu GA, Giannini DT, Oliveira CL, Santos MM, et al. ERICA: intake of macro and micronutrients of Brazilian adolescents. Rev Saude Publica. 2016;50 Suppl 1. https://doi.org/10.1590/s01518-8787.2016050006698
https://doi.org/10.1590/s01518-8787.2016... evaluated Brazilian adolescents and pointed out as nutrients with the highest prevalence of inadequacy the same ones observed in this analysis; for example, calcium (99% prevalence of inadequacy), vitamins A (prevalence inadequacy ranging between 60% and 74%) and E (100% inadequacy prevalence), and sodium (overconsumption prevalence ranging between 79% and 91%).

A 50% inadequacy in phosphorus intake among the adolescents investigated in this analysis was also observed in the Erica study, which found even higher prevalence of inadequacy, between 59% and 65%. The greater inadequacy of phosphorus in this age group is due to the higher recommended intake, approximately twice that recommended for adults²⁰20 Institute of Medicine (US), Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary reference intakes for calcium, phosphorus, magnesium, vitamin d, and fluoride. Washington (DC): National Academies Press; 1997. https://doi.org/10.17226/5776
https://doi.org/10.17226/5776... . The importance of phosphorus in adolescence is also highlighted, along with calcium and vitamin D, for the proper maintenance of bone metabolism and prevention of diseases such as scoliosis and osteoporosis in older ages²¹21 Batista RMBF, Martins DE, Wajchenberg M, Lazaretti M, Puertas EB, Hayashi LF. Association between vitamin d levels and adolescent idiopathic scoliosis. Coluna/Columna. 2014;13(4):275-8. https://doi.org/10.1590/S1808-18512014130400432
https://doi.org/10.1590/S1808-1851201413... .

Studies in Europe, North America, Latin America, Africa, and Asia also point to inadequate nutrient intake in different populations. Each region has specific characteristics regarding the nutrients whose intake by its population is most critical. However, in general, there were high prevalence of inadequate intake of calcium, vitamins A, D, E, zinc, folate, and iron²²22 Roman Viñas B, Ribas Barba L, Ngo J, Gurinovic M, Novakovic R, Cavelaars A, et al. Projected prevalence of inadequate nutrient intakes in Europe. Ann Nutr Metab. 2011;59(2-4):84-95. https://doi.org/10.1159/000332762
https://doi.org/10.1159/000332762... ,²³23 Beal T, Massiot E, Arsenault JE, Smith MR, Hijmans RJ. Global trends in dietary micronutrient supplies and estimated prevalence of inadequate intakes. PLoS One. 2017;12(4):e0175554. https://doi.org/10.1371/journal.pone.0175554
https://doi.org/10.1371/journal.pone.017... . The evolution of nutrient inadequacy was also assessed with data from adults from the North American National Health and Nutrition Examination Survey, from 2003 to 2016. A reduction in inadequacy was observed for most nutrients. Nonetheless, calcium, magnesium, vitamins A, C, D, and E, and folate remained inadequate above 50% in 2015–2016²⁴24 Han S, Wu L, Wang W, Li N, Wu X. Trends in dietary nutrients by demographic characteristics and BMI among US adults, 2003-2016. Nutrients. 2019;11(11):2617. https://doi.org/10.3390/nu11112617
https://doi.org/10.3390/nu11112617... . One should note, however, that although different studies indicate high prevalence of inadequacy for the same nutrients, such results need to be viewed with caution, as research differs in dietary assessment methods, reference values, and analyses used to estimate usual consumption.

Some important aspects about the high prevalence of inadequate intake of calcium and vitamin D need to be pointed out. The reference values for these two nutrients were revised in the last decade, based on the best evidence available at the time²⁰20 Institute of Medicine (US), Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary reference intakes for calcium, phosphorus, magnesium, vitamin d, and fluoride. Washington (DC): National Academies Press; 1997. https://doi.org/10.17226/5776
https://doi.org/10.17226/5776... . However, to establish these values little or no sun exposure²⁰20 Institute of Medicine (US), Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary reference intakes for calcium, phosphorus, magnesium, vitamin d, and fluoride. Washington (DC): National Academies Press; 1997. https://doi.org/10.17226/5776
https://doi.org/10.17226/5776... was assumed, which may not be applicable in countries with a predominantly tropical climate, such as Brazil. Part of the need for vitamin D can be met by synthesis from sun exposure. Accordingly, in a study carried out in the city of São Paulo, almost 100% of the population had inadequate intake of vitamin D, but approximately half of the people had an adequate serum level²⁵25 Martini LA, Verly Jr E, Marchioni DM, Fisberg RM. Prevalence and correlates of calcium and vitamin D status adequacy in adolescents, adults, and elderly from the Health Survey-São Paulo. Nutrition. 2013;29(6):845-50. https://doi.org/10.1016/j.nut.2012.12.009
https://doi.org/10.1016/j.nut.2012.12.00... .

Calcium requirements are also a source of intense debate, involving both the adequacy of balance studies and the non-confirmation of beneficial effects for bone health in meta-analyses of longitudinal studies²⁶26 Willett WC, Ludwig DS. Milk and health. N Engl J Med. 2020;382(7):644-54. https://doi.org/10.1056/nejmra1903547
https://doi.org/10.1056/nejmra1903547... . However, despite criticisms of reference values, the frequency of consumption of foods that are sources of calcium and vitamin D, such as dairy products and fish, has been very low since the 2008–2009¹⁰10 Instituto Brasileiro de Geografia e Estatística, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento. Pesquisa de Orçamentos Familiares 2017-2018: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2020 [cited 2020 Oct 29]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101742.pdf
https://biblioteca.ibge.gov.br/visualiza... .

Excessive and inadequate consumption of sodium remained between the two surveys, a result in line with the 2013 National Health Survey, which estimated the consumption of salt in the Brazilian population by the urinary excretion of sodium. The verified consumption, higher among men, was twice the maximum amount of intake recommended by the World Health Organization²⁷27 Mill JG, Malta DC, Machado IE, Pate A, Pereira CA, Jaime PC, et al. Estimativa do consumo de sal pela população brasileira: resultado da Pesquisa Nacional de Saúde 2013. Rev Bras Epidemiol. 2019;22 Supl 2:E190009.Supl.2. https://doi.org/10.1590/1980-549720190009.supl.2
https://doi.org/10.1590/1980-54972019000... .

The high prevalence of excessive sodium intake has been a concern for decades in Brazil²⁸28 Malta DC, Morais Neto OL, Silva Junior JB. Apresentação do Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas não Transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saude. 2011;20(4):425-38. https://doi.org/10.5123/S1679-49742011000400002
https://doi.org/10.5123/S1679-4974201100... and worldwide²⁹29 World Health Organization. Guideline: sodium intake for adults and children. Geneva (CH): WHO; 2012 [cited 2020 Oct 29]. Available from: https://apps.who.int/iris/handle/10665/77985
https://apps.who.int/iris/handle/10665/7... . The excessive consumption, associated with a diet low in potassium, increases blood pressure levels and represents a risk for the development of arterial hypertension, which in turn has been listed as one of the most important risk factors for morbidity and mortality from cardiovascular diseases³⁰30 O’Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet. 2010;376(9735):112-23. https://doi.org/10.1016/s0140-6736(10)60834-3
https://doi.org/10.1016/s0140-6736(10)60... . Another outstanding result was the increase, among the elderly, of riboflavin inadequacy, a vitamin that can exert neuroprotective effects for some neurological disorders (for example, Parkinson’s disease, migraine, and multiple sclerosis), with milk and dairy products, viscera, and beef as its main sources³¹31 Saedisomeolia A, Ashoori M. Riboflavin in human health: a review of current evidences. Adv Food Nutr Res. 2018;83:57-81. https://doi.org/10.1016/bs.afnr.2017.11.002
https://doi.org/10.1016/bs.afnr.2017.11.... .

Individuals with lower per capita household income were those with the highest prevalence of inadequacy for most of the investigated nutrients. Similarly, in general, poorer regions of the country had higher prevalence of inadequacy. Studies with the North American population also showed that, among adults of low socioeconomic status, the proportion of individuals with inadequate nutrient intake increased²⁴24 Han S, Wu L, Wang W, Li N, Wu X. Trends in dietary nutrients by demographic characteristics and BMI among US adults, 2003-2016. Nutrients. 2019;11(11):2617. https://doi.org/10.3390/nu11112617
https://doi.org/10.3390/nu11112617... , while at higher income levels the risk of inadequacy decreased³²32 Bailey RL, Akabas SR, Paxson EE, Thuppal SV, Saklani S, Tucker KL. Total usual intake of shortfall nutrients varies with poverty among US adults. J Nutr Educ Behav. 2017;49(8):639-46.e3. https://doi.org/10.1016/j.jneb.2016.11.008
https://doi.org/10.1016/j.jneb.2016.11.0... .

The socioeconomic and demographic disparities highlighted here have already been observed in other analyses of the 2008–2009 survey³³33 Araujo MC, Verly Junior E, Junger WL, Sichieri R. Independent associations of income and education with nutrient intakes in Brazilian adults: 2008-2009 National Dietary Survey. Public Health Nutr. 2014;17(12):2740-52. https://doi.org/10.1017/s1368980013003005
https://doi.org/10.1017/s136898001300300... and in other samples of Brazilian population base³⁴34 Verly Junior E, Cesar CLG, Fisberg RM, Marchioni DM. Socio-economic variables influence the prevalence of inadequate nutrient intake in Brazilian adolescents: results from a population-based survey. Public Health Nutr. 2011;14(9):1533-8. https://doi.org/10.1017/s1368980011000760
https://doi.org/10.1017/s136898001100076... . These disparities were also observed in the assessment of food consumption using the same database, with a reduction in the frequency of fruit consumption between 2008–2009 and 2017–2018, more pronounced in the lowest quartile of income. In contrast, the 2017–2018 results showed that typically Brazilian foods, such as rice, beans, manioc flour, corn and corn-based foods were consumed more frequently among low-income individuals¹⁰10 Instituto Brasileiro de Geografia e Estatística, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento. Pesquisa de Orçamentos Familiares 2017-2018: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2020 [cited 2020 Oct 29]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101742.pdf
https://biblioteca.ibge.gov.br/visualiza... .

Regional differences were observed along with income differences. Foods such as cassava flour, corn, and corn-based foods were more frequently consumed in poorer regions such as the North and Northeast, respectively. On the other hand, the South and Southeast regions had the highest average per capita consumption of fruits and vegetables¹⁰10 Instituto Brasileiro de Geografia e Estatística, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento. Pesquisa de Orçamentos Familiares 2017-2018: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2020 [cited 2020 Oct 29]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101742.pdf
https://biblioteca.ibge.gov.br/visualiza... . Also noteworthy is that results of the POF 2017–2018 also showed how the regular and permanent access of households to quality food in sufficient quantity is unequal in Brazil. The North and Northeast regions had the lowest proportions of private households in food security situation. Less than half of the residents of these regions had full and regular access to food⁵5 Instituto Brasileiro de Geografia e Estatística, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento. Pesquisa de Orçamentos Familiares 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro: IBGE; 2020 [cited 2020 Oct 29]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101749.pdf
https://biblioteca.ibge.gov.br/visualiza... . Therefore, any strategy that aims to improve nutrient intake in Brazil needs to emphasize access to adequate food for the most disadvantaged individuals living in the poorest regions.

This study has some limitations. First, nutrient intake did not consider the information on the use of nutritional supplements collected in the last survey. Individuals were only asked about their use in the last 30 days, but without information on the amount and frequency consumed. Therefore, was not possible to estimate the amount of nutrients provided by supplements. The use of multivitamins, B-complex vitamins, and vitamin C was reported by 11.1% of the population, ranging up to 19.5% in elderly women, and the use of calcium supplementation was reported by 4.6%, ranging up to 21.3%, also in elderly women.

The second limitation was the change in the collection method of food consumption, which makes it difficult to compare the two surveys. The change occurred because validation studies systematically showed that collection using computer-assisted R24h decreases the underreporting of energy, sodium, potassium, and protein³⁵35 Park Y, Dodd KW, Kipnis V, Thompson FE, Potischman N, Schoeller DA, et al. Comparison of self-reported dietary intakes from the Automated Self-Administered 24-h recall, 4-d food records, and food-frequency questionnaires against recovery biomarkers. Am J Clin Nutr. 2018;107(1):80-93. https://doi.org/10.1093/ajcn/nqx002
https://doi.org/10.1093/ajcn/nqx002... . Thus, it is believed the change has allowed for more accurate estimates. However, the underreporting of energy intake, common in the collection by R24h, probably led to an overestimated prevalence of inadequacy. However, as caloric intake was similar between both surveys (1,753 kcal in 2008–2009 and 1,748 kcal in 2017–2018), it is likely that the effect of this possible underreporting was similar.

The high and persistent prevalence of inadequacy verified in this study point to a nutritionally deficient diet, in a context of global syndemic of obesity, malnutrition, and climate change³⁶36 Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, et al. The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. Lancet. 2019;393(10173):791-846. https://doi.org/10.1016/S0140-6736(18)32822-8
https://doi.org/10.1016/S0140-6736(18)32... . Given this scenario, FAO recognizes the challenge of combating poor nutrition in all its forms, including malnutrition, specific nutritional deficiencies, overweight, obesity, and food-related CNCD³⁷37 High Level Panel of Experts, Committee on World Food Security. Investing in smallholder agriculture for food security: a report by the High Level Panel of Experts on Food Security and Nutrition. Rome (IT): HLPE; 2013 [cited 2020 Oct 29]. Available from: http://www.fao.org/3/a-i2953e.pdf
http://www.fao.org/3/a-i2953e.pdf... .

In Brazil, access to adequate food as a right is provided for by law³⁸38 Brasil. Lei N° 11.346, de 15 de setembro de 2006. Cria o Sistema Nacional de Segurança Alimentar e Nutricional – SISAN com vistas em assegurar o direito humano à alimentação adequada e dá outras providências. Brasília, DF; 2006 [cited 2021 Mar 9]. Available from: http://www.planalto.gov.br/ccivil_03/_ato2004-2006/2006/lei/l11346.htm
http://www.planalto.gov.br/ccivil_03/_at... and incorporated into the Federal Constitution³⁹39 Brasil. Emenda Constitucional, N° 64, de 4 de fevereiro de 2010. Altera o art. 6° da Constituição Federal, para introduzir a alimentação como direito social. Brasília, DF; 2010 [cited 2021 Mar 9]. Available from: www.planalto.gov.br/ccivil_03/constituicao/emendas/emc/emc64.htm
www.planalto.gov.br/ccivil_03/constituic... . From this perspective, physical and economic access to food must ensure not only sufficient food, but also adequate nutrition. However, as shown here, nutrient intake has been inadequate among Brazilians.

CONCLUSION

High prevalence of inadequate nutrient intakes and excessive sodium intake were found in both surveys. The prevalence of inadequacy changes according to sociodemographic variables, increasing among individuals in the lowest income strata and in the poorest regions of the country.

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