Proposal for a breakfast quality index for brazilian population: Rationale and application in the Brazilian National Dietary Survey
Introduction
Diet plays an important role in preventing and controlling morbidity and premature mortality resulting from nutritional deficiencies and noncommunicable diseases (World Health Organization [WHO], 2003). In this context, a balanced daily breakfast is an important meal which supplies essential nutrients and helps balance the diet, providing appreciable proportions of daily energy, macronutrient, and micronutrient intakes (Nicklas et al., 2000, Pinto and Carbajal, 2003, Barr et al., 2013).
There is some evidence suggesting that breakfast frequency and quality may be associated with appetite and glycemic control (Pereira et al., 2011), daily energy intake (Schusdziarra et al., 2011), nutrient intake and diet quality (Barr et al., 2013, Matthys et al., 2007, Kant et al., 2008, Deshmukh-Taskar et al., 2010, Barr et al., 2014, O'Neil et al., 2014b). These aspects may influence weight control over time (Albertson et al., 2007, Blondin et al., 2016, Timlin and Pereira, 2007), as well as visceral fat levels (Alexander et al., 2009) and changes in risk factors for diseases such as diabetes, hypertension, dyslipidemia and cardiovascular disease (Timlin and Pereira, 2007, Smith et al., 2010, Cahill et al., 2013, Hallström et al., 2013, Odegaard et al., 2013, Yoo et al., 2014, Bi et al., 2015, Wennberg et al., 2015, Kubota et al., 2016).
Despite its clear importance, criteria for an ideal composition of breakfast, including types and amounts of foods, nutrients, and energy are not well established. There is a variety of breakfast quality indexes in the literature, and most of them follow a similar rationale of the diet quality indexes, expressing the overall healthiness of the meal or diet, respectively. In general, these indexes are a summary measure of the diet or meal quality and not a description of their pattern. Therefore, individuals may have a similar score with different contributing components, and thus different dietary patterns (Moeller et al., 2007, Ocké, 2013). Nevertheless, the indexes are constructed based on a specific meal or dietary pattern that is known to be healthy or based on pre-existing dietary guidelines for the population (Ocké, 2013), and usually add points for appropriate foods, but not deduct points for inappropriate food choices. Two well-known examples of dietary quality indexes are the Healthy Eating Index (Guenther, Reedy, & Krebs-Smith, 2008) and the Mediterranean Diet Score (Trichopoulou et al., 1995). The strength of scores of diet quality is that they rely on the body of scientific evidence from studies on health and disease prevention. However, there is insufficient knowledge and consensus on what actually is the healthiest diet (Ocké, 2013). In spite of this, studies evaluating the relationship between health and diet quality demonstrate that higher dietary quality is consistently inversely related to CVD and all-cause mortality (Kant, 2004, Reedy et al., 2014).
The majority of the breakfast quality indexes are developed for children and adolescents, based on core food groups outlined in national dietary guidelines (O'Sullivan et al., 2009, Morales et al., 2011, O'Dea and Wagstaff, 2011, Hallström et al., 2012, Fugas et al., 2013;; Monteagudo et al., 2013) and very few include nutrient criteria (Monteagudo et al., 2013). O'Neil, Byrd-Bredbenner, Hayes, Jana, Klinger, & Stephenson-Martin (2014) proposed some nutrient criteria to define a quality breakfast based on the 2010 Dietary Guidelines for Americans and the US School Breakfast program guidelines while also taking into consideration the nutrients of concern in the US population. Another study of 12,316 adults from NHANES evaluated breakfast quality according to energy density (ED) and food group combinations reported for breakfast (Kant et al., 2008). Findings suggest that a lower ED of breakfast was associated with a lower overall dietary ED and a higher micronutrient and fiber intake and lower body weight.
In Brazil, one study of adolescents proposed that the standard breakfast should contain food sources of calcium and energy (Gambardella, Frutuoso, & Franchi, 1999). The calcium should come from milk and dairy products, which also provide a source of zinc and protein, and the energy source should come from breads and biscuits with a topping such as jam, honey, margarine, butter, mayonnaise, cheese or cold cuts. Another study with Brazilian university students (Alves & Boog, 2007), adapted from Gambardella et al. (1999) criteria, proposed that breakfast could be classified as: standard (calcium and energy sources as outlined above); full (calcium and energy sources plus foods rich in vitamins and minerals, such as fruits and vegetables); or partial (any other food not included in the full or standard breakfast described). The Dietary Guidelines for the Brazilian population do not recommend amounts of foods or nutrients specifically at breakfast, however they give examples of quality breakfast meals according to Brazilian habits and recommend the consumption of natural or minimally processed foods, such as fruits, coffee and milk, and culinary preparations based on cereals or tubers, such as cassava (Brasil, 2014).
Although there is some evidence suggesting a relationship between breakfast quality, nutrition and health outcomes, there is no available tool to evaluate the quality of this meal in Brazilian population. In this context, the aim of the present study was to propose a breakfast quality index for the Brazilian population, and to describe the relationship between breakfast quality, socio-demographic factors, and dietary intake at breakfast and for the total day.
Section snippets
Study sample
The present paper analyses data from the first Brazilian National Dietary Survey (BNDS), a dietary intake assessment study at the individual level conducted as a part of the Brazilian Household Budget Survey (HBS), a large cross-sectional population-based study performed from March 2008 to March 2009 (Pereira, Souza, Duffey, Sichieri, & Popkin, 2015).
The BNDS collected dietary data from a representative sample of 34,003 Brazilian individuals aged ≥10 years randomly selected from about 25% of
Results
Breakfast consumers comprised 11,719 women (53%) and 10,560 men (47%) with an average age of 43 years (SE = 0.2). About 48% had breakfast at 7 a.m., with an average of 279 kcal (SE = 2.7). Forty-seven percent of the consumers were normal weight, 42% lived in the Southeast region of Brazil, 83% in an urban area, 60% had up to 9 years of schooling and per capita family income of more than one minimum wage per month. Compared with breakfast skippers (n = 2971 adults), breakfast consumers were
Discussion
To the best of our knowledge this is the first index proposed to evaluate the quality of breakfast of the Brazilian population constructed based on food groups, energy and nutrient intakes. The majority of the population (71%) had a BQI score of 4–6 points and were subsequently categorized as having a medium quality breakfast whereas only about 6% of individuals were categorized as having a high quality breakfast (7–10 points). Individuals with the highest per capita family income and
Conflict of interest disclosure
S. Hopkins is employed by Cereal Partners Worldwide (CPW) SA, Switzerland.
C. Gugger is employed by General Mills Bell Institute of Health and Nutrition.
M. Fisberg is speaker in events for Abbott, Abitrigo and Abimassa. Danone Research, EMS and Nestle. Member of the Board of Danone Institute International. Project grants from CPW, Coca-Cola and Danone Research.
J.L. Pereira and M.A. Castro are researchers from Food Consumption Research Group from the School of Public Health of the University of
Acknowledgements
Funding for this study was provided by Cereal Partners Worldwide (CPW) SA, Switzerland and the General Mills Bell Institute of Health and Nutrition, Minneapolis, MN, USA. Authors did not allow any participation of sponsors and other commercial interests in the content of the paper. No interference of the sponsors was present in this manuscript. The authors thank Jessica Smith, PhD, for the manuscript review.
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