Trends in spending on eating away from home in Brazil, 2002-2003 to 2008-2009

Three decades of household food availability according to NOVA - Brazil, 1987-2018

OBJECTIVE

To evaluate the trend of household food acquisition according to the NOVA classification in Brazil between 1987–1988 and 2017–2018.

METHODS

We used household food acquisition data from five editions of the Pesquisas de Orçamentos Familiares (Household Budget Surveys), conducted by the Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics), in the years 1987–1988, 1995–1996, 2002–2003, 2008–2009, and 2017–2018. All reported foods were categorized according to the NOVA classification. The household availability of food groups and subgroups was expressed through their share (%) in total calories, for all Brazilian families, by household situation (urban or rural), for each of the five geographic regions of the country, by fifths of the household income per capita distribution (2002–2003, 2008–2009 and 2017–2018 surveys), and for the 11 main urban regions of the country (1987–1988, 1995–1996, 2002–2003, 2008–2009 and 2017–2018 surveys). Linear regression models were used to assess the trend of increasing or decreasing food purchases.

RESULTS

The diet of the Brazilian population is still composed predominantly of foods in natura or minimally processed and processed culinary ingredients. However, our findings point to trends of increasing share of ultra-processed foods in the diet. This increase of 0.4 percentage points per year between 2002 and 2009 slowed down to 0.2 percentage points between 2008 and 2018. The consumption of ultra-processed food was higher among households with higher income, in the South and Southeast regions, in urban areas, and in metropolitan regions.

CONCLUSION

Our results indicate an increase in the share of ultra-processed foods in the diet of Brazilians. This is a worrisome scenario, since the consumption of such foods is associated with the development of diseases and the loss of nutritional quality of the diet.

Acquisition of food for away-from-home consumption in Brazil between 2002 and 2018

The aim of the study was to assess the evolution of food acquisition for away from home consumption in Brazil from 2002 to 2018. The trend of food purchases for out-of-home consumption in Brazil was evaluated by comparing food purchase data from the Household Budget Surveys (HBS) of 2002-2003, 2008-2009, and 2017-2018. The frequency of food acquisition was estimated according to sociodemographic variables and the mean cost. In 2002-2003, the frequency of purchase of food for out-of-home consumption was 35.2% (95%CI: 34.4-35.9), increasing to 41.2% (95%CI: 40.4-42.0) in 2008-2009, followed by a decline in 2017-2018 (32.3%; 95%CI: 31.7-32.9). A declining trend was observed in the frequency of purchases of alcoholic beverages and soft drinks and fast foods maintained the frequency between the last two surveys. Spending on this type of food increased between 2002-2003 and 2008-2009, while the mean value of this type of expenditure was maintained between 2008-2009 and 2017-2018. Brazilians increased food purchases for out-of-home consumption between 2002-2003 and 2008-2009, declining in 2017-2018. A consistent fall in the purchase of alcoholic beverages and soft drinks was observed over time, while the group of meals grew significantly.

Systematic literature review of instruments that measure the healthfulness of food and beverages sold in informal food outlets

BACKGROUND

Informal food outlets, defined as vendors who rarely have access to water and toilets, much less shelter and electricity, are a common component of the food environment, particularly in many non-Western countries. The purpose of this study was to review available instruments that measure the quality and particularly the healthfulness of food and beverages sold within informal food outlets.

METHODS

PubMed, LILACS, Web of Science, and Scopus databases were used. Articles were included if they reported instruments that measured the availability or type of healthy and unhealthy foods and beverages by informal food outlets, were written in English or Spanish, and published between January 1, 2010, and July 31, 2020. Two trained researchers reviewed the title, abstract and full text of selected articles; discrepancies were solved by two independent researchers. In addition, the list of references for selected articles was reviewed for any additional articles of relevance. The quality of published articles and documents was evaluated using JBI Critical appraisal checklist for analytical cross-sectional studies.

RESULTS

We identified 1078 articles of which 14 were included after applying the selection criteria. Three additional articles were considered after reviewing the references from the selected articles. From the final 17 articles, 13 measurement tools were identified. Most of the instruments were used in low- and middle-income countries (LMIC). Products were classified as healthy/unhealthy or produce/non-produce or processed/unprocessed based on availability and type. Six studies reported psychometric tests, whereas one was tested within the informal food sector.

CONCLUSIONS

Few instruments can measure the healthfulness of food and beverages sold in informal food outlets, of which the most valid and reliable have been used to measure formal food outlets as well. Therefore, it is necessary to develop an instrument that manages to measure, specifically, the elements available within an informal one. These actions are extremely important to better understand the food environment that is a central contributor to poor diets that are increasingly associated with the obesity and Non-communicable disease (NCD) pandemic.

Evolution of out-of-home food consumption in Brazil in 2008-2009 and 2017-2018

OBJECTIVE

To describe the evolution of out-of-home food consumption in Brazil in 2008–2018.

METHODS

We used the 2008–2009 and 2017–2018 data from the Inquéritos Nacionais de Alimentação (INA - National Food Surveys), conducted amid 34,003 and 46,164 individuals, to estimate the frequency of out-of-home food consumption and the contribution of this consumption to specific foods. Food consumption was analyzed using food records in the 2008–2009 INA and 24-hour recalls in 2017–2018. Estimates were generated for Brazil in general, for urban and rural areas, for age groups (adolescent, adult, elderly), and for income bracket.

RESULTS

The frequency of out-of-home consumption decreased by 8.8% between the two surveys, with no change in the rural area, in the Northeast and South regions, and for the lowest income brackets. We observed a slight increase among the elderly and in the Midwest region. The contribution of out-of-home food consumption to daily energy intake also decreased (16.3% vs. 12.7%), excepting the rural area, where there was a reduction in the difference in relation to the urban area between the two surveys. For most items evaluated, the out-of-home food consumption decreased. The most consumed out-of-home food were alcoholic beverages, fried and baked snacks, soft drinks, pizza, sweets, and sandwiches in both surveys.

CONCLUSION

In 10 years, the prevalence of food consumption and the percentage of contribution of out-of-home food decreased in Brazil, but ultra-processed foods still figure as the most consumed food group outside the home.

Factors associated with diet changes during the COVID-19 pandemic period in Brazilian adults: Time, skills, habits, feelings and beliefs

This study aimed to identify individual, household and sociodemographic factors associated with changes in food consumption that lead to changes in the diet quality, in the context of the COVID-19 pandemic concerning Brazilian adults. Improvements or worsening in diet quality (IDQ or WDQ) were verified using an exploratory online survey which investigated whether participants (n = 4780) increased or decreased their consumption of food subgroups that mark positive or negative food patterns. Respondents also agreed or disagreed with their beliefs about food safety, cooking skills, family support, home characterization, feelings and behaviors. All factors of influence on the IDQ or WDQ groups were always compared against the general participants (who did not change their diet sufficiently to be classified into these groups). Individuals from the IDQ group spent more time on food (81.4% versus 62.0%), started to cook more often (91.4%), were more confident with their cooking skills (p < 0.01) and positive feelings were at least 2.5 times more prevalent. Adjusted analysis showed the chance to improve diet was 1.39 higher among those who did not feel overworked and increased 1.07 in each additional cooking chore shared between household members. For each additional positive feeling, the odds were 1.41 to IDQ and 0.67 to WDQ. Moreover, for each additional negative feeling the chances for WDQ were 1.21 and 0.90 for IDQ. Those in the WDQ group were more unaware of issues related to contagion during meals, they were not afraid of eating food prepared outside their home and agreed that industrialized food is safer (OR = 1.85). These results highlight the associated factors in improving or worsening diet patterns as a consequence of the COVID-19 pandemic, supporting messages presented in Dietary Guidelines.

[Eating away from home and biomarkers for chronic noncommunicable diseases in Brazilian adolescents]

The study aimed to assess the relationship between food consumption away from home and alterations in biomarkers for chronic noncommunicable diseases in Brazilian adolescents. This cross-sectional study used data from the Study of Cardiovascular Risk Factors in Adolescents (ERICA), conducted in 36,956 adolescents in 2013/2014. The relationship between food consumption away from home and each target outcome (hypertriglyceridemia, hypercholesterolemia, hyperglycemia, high glycated hemoglobin, and hyperinsulinemia) was tested with logistic regression models adjusted for age, school system (public versus private), physical activity, and screen time. Data on food consumption were obtained with a 24-hour diet recall (24HR), analyzing consumption of energy, added sugar, sodium, potassium, fiber, fruits, vegetables, rice, beans, sandwiches, cakes, dessert, chocolates, and sodas. The results showed that 53.2% of adolescents consumed foods away from home. Eating away from home showed an inverse relationship with hyperinsulinemia (OR = 0.65; 95%CI: 0.46-0.92) and hyperglycemia (OR = 0.46; 95%CI: 0.30-0.71) in boys and hypertension (OR = 0.71; 95%CI: 0.55-0.92) and hyperglycemia (OR = 0.57; 95%CI: 0.34-0.96) in girls. However, the consumption of calories, added sugar, sandwiches, desserts, and sodas was higher in adolescents that consumed foods away from home. The protective role of eating away from home, as measured by biochemical indicators in adolescents, may be a function of higher consumption of school meals, which was more frequent among adolescents that consumed food away from home, thus highlighting the importance of encouraging consumption of school meals.

Reduction of traditional food consumption in Brazilian diet: trends and forecasting of bean consumption (2007-2030)

OBJECTIVE

To identify changes in traditional dietary behaviour through the evaluation of trends in bean consumption among adults in Brazil between 2007 and 2017 and to estimate its projections up to 2030.

DESIGN

Time-series analysis conducted with data from the Surveillance System for Protective and Risk Factors for Chronic Diseases by Telephone Survey (Vigitel) between 2007 and 2017. Weekly consumption of beans was analysed. Prais-Winsten regression evaluated trends for the entire period of study (2007-2017) and in two periods of analyses (2007-2011 and 2012-2017) for the complete set of the population and stratified by socio-demographic characteristics. Estimated prevalence projections were calculated up to the year 2030 using its tendency from 2012 to 2017.

SETTING

Brazil.

PARTICIPANTS

A probabilistic sample of 572 675 Brazilian adults aged ≥ 18 years.

RESULTS

Changes in traditional dietary pattern were identified. Regular consumption of beans (≥ 5 d/week) presented a stable prevalence trend for the total population in the complete and the first analysed period, but a significant decrease in the second half (67·5 % to 59·5 %) among both genders, all age groups and educational levels (except for ≥12 years). The higher magnitude of regular consumption of beans will occur up to the year of 2025 for the total population (46·9 %), when it will be less frequent in the week.

CONCLUSION

Reductions in the weekly consumption of beans may represent the weakness of a traditional food culture in a globalised food system. By 2025, regular consumption of beans will cease to be the predominant habit in the country.

Developing and refining behaviour-change messages based on the Brazilian dietary guidelines: use of a sequential, mixed-methods approach

Background

Dietary Guidelines are an important tool for population health promotion efforts. However, current surveillance data suggest that only a small minority of the population meet the 2014 Brazilian Dietary Guidelines (BDG) recommendations. Translating recommendations into practice may not be immediately clear and behavior-change messages guiding the behaviors that need to be changed and identifying substitute practices to meet a specific recommendation, are required. This study details the methods undertaken to develop and refine messages supporting the adoption of healthy dietary choices and behaviors in adults, as outlined in the BDG.

Methods

A sequential, five-step, mixed-methods approach, determined a priori, was followed for designing and refining messages. These included: (1) content extraction; (2) audience analysis; (3) input from an expert review panel; (4) message development and message refinement; and a (5) test of content validity.

Results

The content extraction process led to the identification of 63 excerpts from the BDG, organized into themes. The audience analysis highlighted barriers to healthy eating that included lack of time (to eat, to cook), difficulty in accessing healthy food, the convenience and the ubiquitous marketing of ultra-processed foods. Twenty of the 63 DG excerpts reviewed by the expert panel were identified as being a priority for message development and total of 111 messages were developed. Messages were short, structured to be one-sided, conveyed the most important information at the beginning (anticlimactic), used simple language and were explicit in the information they relayed. They were positive and gain-framed and used an empathetic, solution- or substitution-based tone and were presented in the active voice. The messages focused on goals and skill development, behavior regulation, incentivized positive practices as time and/or cost saving. Content validity testing helped further messages and reduced the number of messages from 111 to 40.

Conclusions

This study provides the blue-print for the phase-wise development of messages that synthesize the key recommendations of the food-based BDG and communicate the adoption of behaviors and goals that are consistent with it’s message. It details methods which could be adapted and replicated for message development in other contexts.

Life cycle environmental impacts of food away from home and mitigation strategies-a review

Food production and consumption are major drivers of global environmental change, endangering the safe operating space of many environmental areas. Globally, there has been a growing trend of dining out, termed food away from home (FAFH) here, but its environmental sustainability has received insufficient attention. In this review, we examine studies quantifying the life-cycle environmental impacts of FAFH and identify mitigation strategies across the food supply chain. Overall, previous life cycle assessment (LCA) studies focused on the composition of FAFH meals and pre-use life cycle stages, especially food production. Greenhouse gas (GHG) emissions of FAFH meals range from 0.134 kg CO₂ e/meal to 13.2 kg CO₂ e/meal for school canteen meals, and from 0.60 kg CO₂ e/meal to 9.6 kg CO₂ e/meal for other catering services. Meat ingredients are the dominant source in a variety of environmental impact categories, and the food production stage usually accounts for over half of the total GHG emissions in the FAFH life cycle. Supply side mitigation strategies include advancing farming practices, updating cold transportation technology, and improving building energy efficiency. Demand side mitigation focuses on dietary change towards meals with less meat ingredients, with nudging and sustainable menu-designing as the two primary groups of strategies. Areas of focus for LCA include improving modeling of building energy consumption related to food consumption, advancing uncertainty characterization of life cycle results, and capturing geographical variations in food production.

The consumption of ultra-processed foods according to eating out occasions

Objective:

To describe out-of-home consumption according to the purpose and extent of industrial processing and also evaluate the association between eating out and ultra-processed food consumption, taking account of variance within and between individuals.

Design:

Cross-sectional study.

Setting:

Brazil.

Participants:

The study was based on the Individual Food Intake of the Brazilian Household Budget Survey, carried out with 34 003 individuals aged 10 years or more, between May 2008 and May 2009. All food items were classified according to food processing level. The habit of eating out was evaluated through the frequency of days each individual reported eating out, described according to sociodemographic characteristics. The contribution of food energy per group and subgroup was estimated according to the frequency of eating out. In addition, multilevel modelling was employed to evaluate the association between eating out and ultra-processed food consumption.

Results:

In Brazil, culinary preparations accounted for most of the energy eaten out. However, it was possible to observe a higher contribution of ultra-processed foods, especially sugary beverages and ready-to-eat meals, as the frequency of out-of-home consumption increased. Compared with food consumption exclusively at home, eating out increased the consumption of ultra-processed foods by 0·41 percentage points within and between individuals.

Conclusion:

In Brazil, the same individual and different individuals had greater consumption of ultra-processed foods when they ate out of home compared with when they ate at home. So, it is necessary to implement public policies which discourage the out-of-home consumption of ultra-processed foods and that provide affordable and accessible less-processed food options.

Knowledge and risk perceptions of foodborne disease by consumers and food handlers at restaurants with different food safety profiles

Food handlers and consumers are responsible for avoiding foodborne diseases (FBD). Considering the meals consumed away from home, can the consumer identify the FBD risk level of the food that he/she consumes in restaurants? This study aimed to evaluate the knowledge, risk perception, and optimistic bias of food handlers and consumers of restaurants and the relationship of these variables with the FBD risk of these establishments. Sixty-four handlers and 265 consumers of 14 restaurants in the city of Limeira - São Paulo, Brazil participated in the study. A validated checklist was used to evaluate the food safety profile of restaurants with a score ranging from zero to 2565.95. A structured questionnaire was employed to assess knowledge of food safety and the risk perception of FBD. The food handlers indicated their own risk and their peers' risk of causing a FBD. Consumers evaluated their own risk and the risk of their peers of contracting a FBD after making their own meals, consuming meals at the studied restaurants and consuming meals in other food establishments. The answers were based on a structured scale with seven options. The difference between their risk perception levels (risk attributed to itself and to a peer) indicated the optimistic bias of FBD risk. The mean food safety risk score of the food service establishments was 105.51. The restaurants were classified into two groups, higher or lower FBD risk. The mean score of knowledge (percentage of correct answers) of food safety was 61.7% for handlers and 59% for consumers, showing a nonsignificant difference (p = .29). Both food handlers and consumers stated that they were less at risk for FBD than their peers (p < .001). A direct effect of consumers' optimistic bias on food service FBD risk was observed through multivariate analysis. Optimistic bias may lead consumers to choose restaurants with a higher FDB risk. A direct negative effect of food handlers' knowledge of food service FBD risk was observed. These results show that consumers may have incorporated a sense of affection and identity to a place, associating it with making their own meals at home. Therefore, the consumer may not differentiate restaurants with regard to food safety. This result reinforces the need for governments and health agencies to protect the health of the population.

Food safety performance and risk of food services from different natures and the role of nutritionist as food safety leader

Abstract The objective of this study was to evaluate the food safety performance of food services and its associated factors. The study involved 84 food businesses in the city of Santos as follows: street food kiosks and beach kiosks (street food), commercial restaurants, hospitals and school meal services (institutional food services). A food safety checklist with 81 items was applied. The overall percentage of adequacy was lower in street food kiosk (49.7%) and beach kiosk (62.0%) than in restaurants (69.7%), hospitals (83.9%) and schools (86%). Institutional and commercial restaurants showed higher scores of food safety performance than street food services, mainly regarding risker practices. The variables positively associated with food safety performance in commercial restaurants were: presence of a nutritionist as leader and adequate structure. These results show that street food services need, in a mediate way, the implementation of new strategies and regulations to improve food safety. A nutritionist acting as food safety leader may improve the food safety performance at commercial restaurants.

Qualitative and quantitative analysis of the relevance, clarity, and comprehensibility of the Scale of Quality of Diet (ESQUADA)

The study of the diet quality should include not just the nutritional adequacy but also incorporate the multidimensional understanding and the current dietary recommendations. This study aimed to evaluate the relevance, clarity, and comprehensibility of the Scale of Quality of Diet (ESQUADA). Nutritionists’ perspectives about the relevance and clarity of the items were evaluated through focus groups between November and December 2016. An exploratory content analysis investigated the themes that emerged from the focus groups, which were organized in a structured codebook. Two reviewers applied it to the data. Inter-rater reliability was analyzed by the kappa coefficient. The coding was analyzed using the frequencies and central aspects of the sub-themes. Laypersons’ comprehension of the items was evaluated using a question regarding whether they understood each item in online questionnaire in February 2018. Descriptive statistics investigated the comprehensibility of each item. The reviewers presented adequate reliability on coding the data. Three themes emerged from the data considering the nutritionists’ suggestions. The theme Item relevance indicated that the items assessed diet quality while considering sociocultural influences. However, the nutritionists suggested attention was needed to how some items were expressed and their response options. Of relevance, the themes Item clarity and Clarity of alternatives primarily encompassed discussions regarding item text (44%) and discrimination of alternatives (24%). The study of the comprehensibility indicated that all items were readily understood. These results support the relevance of the ESQUADA for evaluating quality of diet as well the comprehensibility of all the items by individuals uneducated in public health.

A comparison of drinking behavior using a harmonized methodology (Liq.In 7 ) in six countries

PURPOSE

To assess drinking occasions (volume and type) according to consumption with food in or outside meals, and location, for six countries.

METHODS

A total of 10,521 participants aged 4-65 years from Argentina, Brazil, China, Indonesia, Mexico and Uruguay completed a validated 7-day fluid intake record. For each drinking event, the volume consumed, the fluid type, the location of intake, and whether the drink was accompanied by food (meal or snack) or not, was recorded.

RESULTS

Similar drinking behaviors were found in Mexico and Argentina; fluid intake during meals was 48 and 45% of total fluid intake (TFI), respectively. In Brazil (55%), Indonesia (58%) and China (66%) most fluid was consumed without food. In Uruguay, 34% of TFI was with a main meal, 31% with food between meals and 35% without food. Indonesia had the highest median (25-75th percentile) TFI; 2520 (1750-3347) mL/day, and China the lowest 1138 (818-3347) mL/day. Water was consumed with meals for 37% of Chinese and 87% of Indonesian participants, while the four Latin-American American countries showed a preference for sweet drinks; 54% in Mexico, 67% in Brazil, 55% in Argentina and 59% in Uruguay. Diversity in fluid type was noted when drinking with food between meals. Apart from China, most drinking occasions (> 75%) occurred at home.

CONCLUSIONS

Three distinct drinking behaviors were identified, namely, drinking with meals, drinking as a stand-alone activity, and a type of 'grazing' (i.e., frequent drinks throughout the day) behavior. Most drinking occasions occurred at home.

Out-of-Home Food Consumers in Brazil: What do They Eat?

Considering the increased contribution of foods consumed outside home and their potential impact on diet, this study aims to identify eating out patterns and their association with nutritional dietary quality in Brazil. We used the Individual Food Intake Survey 2008–2009, conducted with 34,003 individuals aged 10 and up. We used factor analysis by principal component to identify out-of-home eating patterns and linear regression to explore the association between patterns scores and dietary quality. We identified three food patterns. The “Traditional meal” pattern carried more rice, beans, meat, roots and tubers, pasta, vegetables and eggs. The “typical Brazilian breakfast/tea” pattern carried more fresh bread, margarine, milk, cheese and butter. The “Ultra-processed food” pattern carried more ready-to-eat meals and soft drinks. The “traditional meal” pattern was positively associated with calories from proteins, fiber, iron, potassium and sodium densities, whereas “typical Brazilian breakfast/tea” and “ultra-processed food” patterns were positively associated with energy density, the percentage of calories from lipids or carbohydrates, trans fat and free sugar. Out-of-home eating may have a negative impact on nutritional dietary quality when based on ultra-processed food. However, it is possible to maintain a healthy out-of-home diet with adherence to traditional Brazilian cuisine.

Effects of reducing processed culinary ingredients and ultra-processed foods in the Brazilian diet: a cardiovascular modelling study

OBJECTIVE

To estimate the impact of reducing saturated fat, trans-fat, salt and added sugar from processed culinary ingredients and ultra-processed foods in the Brazilian diet on preventing cardiovascular deaths by 2030.

DESIGN

A modelling study.

SETTING

Data were obtained from the Brazilian Household Budget Survey 2008/2009. All food items purchased were categorized into food groups according to the NOVA classification. We estimated the energy and nutrient profile of foods then used the IMPACT Food Policy model to estimate the reduction in deaths from CVD up to 2030 in three scenarios. In Scenario A, we assumed that the intakes of saturated fat, trans-fat, salt and added sugar from ultra-processed foods and processed culinary ingredients were reduced by a quarter. In Scenario B, we assumed a reduction of 50 % of the same nutrients in ultra-processed foods and processed culinary ingredients. In Scenario C, we reduced the same nutrients in ultra-processed foods by 75 % and in processed culinary ingredients by 50 %.

RESULTS

Approximately 390 400 CVD deaths might be expected in 2030 if current mortality patterns persist. Under Scenarios A, B and C, CVD mortality can be reduced by 5·5, 11·0 and 29·0 %, respectively. The main impact is on stroke with a reduction of approximately 6·0, 12·6 and 32·0 %, respectively.

CONCLUSIONS

Substantial potential exists for reducing the CVD burden through overall improvements of the Brazilian diet. This might require reducing the penetration of ultra-processed foods by means of regulatory policies, as well as improving the access to and promotion of fresh and minimally processed foods.

Coronary heart disease mortality, cardiovascular disease mortality and all-cause mortality attributable to dietary intake over 20years in Brazil

BACKGROUND/OBJECTIVES

In the last two decades, in Brazil, there has been a decreasing trend of consumption of in natura or minimally processed food, while intake of ultra-processed food has markedly increased. We estimated the contribution of dietary intake in trends from coronary heart disease mortality (CHDM), cardiovascular disease mortality (CVDM), and all-cause mortality (ACM) over 20years in Brazil.

METHODS

We used a representative sample of Brazilian households located in metropolitan areas to estimate dietary intake in 1987/88 and 2008/09. For both periods, we estimated fractions of CHDM, CVDM, and ACM attributable to healthy (fruits and vegetables) and unhealthy food items (sugar-sweetened beverages, processed and red meat). We also estimated the number of prevented or postponed deaths attributable to these food items.

RESULTS

The fraction of CHDM attributable to all food items increased from 28.6% in 1987/88 to 38.7% in 2008/09. CVDM attributable to food items increased from 13.7% in 1974 to 19.3% in 2008/09. ACM attributable to all food items increased from 20.1% in 1987/88 to 27.3% in 2008/09. Without the decrease in healthy food item consumption, and the increase in unhealthy food items, 3195 deaths from coronary heart disease, 5340 from cardiovascular disease, and 16,970 from all causes could have been prevented or postponed.

CONCLUSIONS

The burden of cardiovascular diseases and mortality attributable to dietary intake has increased over the last 20years in Brazil. These findings suggest a need for a population prevention approach, focused on dietary intake to reduce the burden of disease.

Inspection Score and Grading System for Food Services in Brazil: The Results of a Food Safety Strategy to Reduce the Risk of Foodborne Diseases during the 2014 FIFA World Cup

In 2014, Brazil hosted one of the most popular sport competitions in the world, the FIFA World Cup. Concerned about the intense migration of tourists, the Brazilian government decided to deploy a food safety strategy based on inspection scores and a grading system applied to food services. The present study aimed to evaluate the results of the food safety strategy deployed during the 2014 FIFA World Cup in Brazil. To assess food safety, an evaluation instrument was applied twice in 1927 food service establishments from 26 cities before the start of the competition. This instrument generated a food safety score for each establishment that ranged from 0.0 (no flaws observed) to 2565.95, with four possible grades: A (0.0-13.2); B (13.3-502.6); C (502.7-1152.2); and pending (more than 1152.3). Each food service received a stamp with the grade of the second evaluation. After the end of the World Cup, a study was conducted with different groups of the public to evaluate the acceptance of the strategy. To this end, 221 consumers, 998 food service owners or managers, 150 health surveillance auditors, and 27 health surveillance coordinators were enrolled. These participants completed a survey with positive and negative responses about the inspection score system through a 5-point Likert scale. A reduction in violation scores from 393.1 to 224.4 (p < 0.001) was observed between the first and second evaluation cycles. Of the food services evaluated, 38.7% received the A stamp, 41.4% the B stamp, and 13.9% the C stamp. All positive responses on "system reliability" presented a mean of 4.0 or more, indicating that the public believed this strategy is reliable for communicating risks and promoting food safety. The strategy showed positive results regarding food safety and public acceptance. The deployed strategy promoted improvements in the food safety of food services. The implementation of a permanent policy may be well accepted by the public and may greatly contribute to a reduction in foodborne diseases (FBDs).

A restaurant-based intervention to promote sales of healthy children's menu items: the Kids' Choice Restaurant Program cluster randomized trial

BACKGROUND

Away-from-home eating is an important dietary behavior with implications on diet quality. Thus, it is an important behavior to target to prevent and control childhood obesity and other chronic health conditions. Numerous studies have been conducted to improve children's dietary intake at home, in early care and education, and in schools; however, few studies have sought to modify the restaurant food environment for children. This study adds to this body of research by describing the development and launch of an innovative intervention to promote sales of healthy children's menu items in independent restaurants in Southern California, United States.

METHODS

This is a cluster randomized trial with eight pair-matched restaurants in San Diego, California. Restaurants were randomized to a menu-only versus menu-plus intervention condition. The menu-only intervention condition involves manager/owner collaboration on the addition of pre-determined healthy children's menu items and kitchen manager/owner collaboration to prepare and plate these items and train kitchen staff. The menu-plus intervention condition involves more extensive manager/owner collaboration and kitchen staff training to select, prepare, and plate new healthy children's menu items, and a healthy children's menu campaign that includes marketing materials and server training to promote the items. The primary outcome is sales of healthy children's menu items over an 18-week period. In addition, dining parties consisting of adults with children under 18 years of age are being observed unobtrusively while ordering and then interviewed throughout the 18-week study period to determine the impact of the intervention on ordering behaviors. Manager/owner interviews and restaurant audits provide additional evidence of impact on customers, employees, and the restaurant environment. Our process evaluation assesses dose delivered, dose received, and intervention fidelity.

DISCUSSION

Successful recruitment of the restaurants has been completed, providing evidence that the restaurant industry is open to working on the public health challenge of childhood obesity. Determining whether a restaurant intervention can promote sales of healthy children's menu items will provide evidence for how to create environments that support the healthy choices needed to prevent and control obesity. Despite these strengths, collection of sales data that will allow comprehensive analysis of intervention effects remains a challenge.

TRIAL REGISTRATION

NCT02511938.

Iniquidades no acesso aos benefícios alimentação e refeição no Brasil: uma análise da Pesquisa de Orçamentos Familiares 2008-2009

Considerando que o recebimento de benefícios alimentação e refeição pode ser um determinante da escolha alimentar de trabalhadores, o objetivo do estudo foi avaliar a abrangência do recebimento destes benefícios no Brasil e sua distribuição segundo características sociodemográficas e regionais dos beneficiários. Utilizaram-se dados da Pesquisa de Orçamentos Familiares 2008-2009. Foram elegíveis os indivíduos que referiram ter ocupação e declararam possuir emprego privado, público, doméstico ou temporário na área rural. Apenas 3,2% dos elegíveis referiram receber os benefícios, com maior concentração no Sudeste, área urbana, sexo masculino, empregados no setor privado e recebendo mais de 5 salários mínimos. O valor médio mensal dos benefícios recebidos no Brasil foi R$ 177,20. Após ajuste para as demais variáveis, o valor foi maior entre homens, com salários mais altos, no Nordeste e Centro-oeste e do setor público. Trata-se da primeira análise de abrangência nacional sobre benefícios alimentação e refeição, apontando uma importante parcela de trabalhadores sem acesso ao benefício e iniquidades no acesso.

The existence of optimistic bias about foodborne disease by food handlers and its association with training participation and food safety performance

A positive outlook regarding future events, in which individuals find themselves less likely than others to experience negative events, is called optimistic bias (OB). The aims of this study were: 1. To ascertain the existence and measure the OB phenomenon in food handlers in relation to foodborne disease and 2. To examine the association of OB with food handlers' risk perceptions, knowledge, attitudes, self-reported practices, training participation, food safety performance of the establishments and microbiological analysis. This study examined different food businesses in Santos city, in Brazil, as follows: street food kiosks, beach kiosks, restaurants, hospitals, and school meal services. The food handlers indicated their own risk and their peers' risk of causing a foodborne disease. Responses were given on a 10cm linear scale anchored with descriptors of intensity ranging from "none" to "very high". The difference between these risk perceptions characterized a score of tendency of an OB. A structured questionnaire was administered to evaluate knowledge, attitudes, self-reported practices and food safety performance. A total of 183 food handlers participated in the study. Microbiological analyses were conducted with ready-to-eat foods/preparations from selected sites. The food handlers perceived themselves as less likely than their peers to cause a foodborne disease (p<0.001), demonstrating the tendency of an OB. Food handlers who had undergone some training presented lower scores for the perceived risk of themselves being responsible for a foodborne disease and higher knowledge than did untrained individuals. Hospitals, schools and restaurants performed better than street food group considering food safety performance. However, microorganisms were found in food samples from hospitals. This result may be motivated by OB and other subjective factors. Apparently, this positive outlook of food handlers is associated with training participation, lethality perception and correlating positively with age. No association was found between OB scores and knowledge, attitudes and self-reported practices. Since OB may lead individuals to adopt inappropriate or dangerous behavior, strategies for debiasing food handlers should be designed.