Development of a dietary index based on the Brazilian Cardioprotective Nutritional Program (BALANCE)

Jacqueline Tereza da Silva, Ângela Cristine Bersch-Ferreira, Camila Ragne Torreglosa, Bernardete Weber, Renata Bertazzi Levy, Jacqueline Tereza da Silva, Ângela Cristine Bersch-Ferreira, Camila Ragne Torreglosa, Bernardete Weber, Renata Bertazzi Levy

Abstract

Background: The diet of the Brazilian Cardioprotective Nutritional Program (BALANCE) classifies food into four groups and sets the daily amount to be consumed. The dietary approach of BALANCE is different from other dietary recommendations; therefore, it is not possible to use existing dietary indexes (DI) to assess patient's adequacy to BALANCE diet. For this reason, it is important to develop a specific dietary index based on BALANCE diet. This study aims to describe the development of the BALANCE DI, evaluate its internal consistency, construct and content validity and population characteristics associated with the index.

Methods: We analyzed baseline data from the BALANCE randomized clinical trial ( https://www.clinicaltrials.gov/ ; NCT01620398). The four food groups of the diet were adopted as index components. Points ranging from 0 to 10 were given to each index component. Internal consistency was evaluated by correlation coefficients between total score and component scores, as well as Cronbach's Alpha. Content and construct validity were assessed by checking how nutrients are associated with the index and if the index could distinguish between groups with known differences in diet, respectively. Crude and adjusted linear regression analyses were performed to evaluate population characteristics associated with the index.

Results: The analysis included 2044 subjects (58.6% men). The average of the total index was higher among women (p < 0,05). The components of the index showed low correlations with each other. The correlations between each individual component with the total index were > 0.40. Cronbach's alpha coefficient was 0.66. High scores in the index were inversely associated (p < 0,05) with energy, total fat, monounsaturated fat (MUFA) and cholesterol; they were positively associated (p < 0,05) with carbohydrates and fiber. Hypertensive men and diabetic women had higher scores, while male smokers had lower scores.

Conclusions: The BALANCE DI showed reliability and construct validity similar to other DI. It also detected characteristics of individuals that are associated with higher or lower index scores.

Keywords: Cardiovascular disease; Dietary assessment; Nutritional index, dietary patterns; Reliability and validity.

Conflict of interest statement

Ethics approval and consent to participate

The present analysis was approved by the School of Public Health / University of São Paulo Research Ethics Committee.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

    1. World Health Statistics. Geneva: World Health Organization; 2015.
    1. Mansur AP, Favarato D. Trends in mortality rate from cardiovascular disease in Brazil, 1980-2012. Arq Bras Cardiol. 2016;107:20–25.
    1. Burlingame B, Dernini S. Sustainable diets and biodiversity: directions and solutions for policy, research and action. Rome, Italy: Nutrition and Consumer Protection Division FAO; 2012.
    1. Weber B, Bersch-Ferreira Â, Torreglosa CR, Ross-Fernandes MB, da Silva JT, Galante AP, et al. The Brazilian Cardioprotective nutritional program to reduce events and risk factors in secondary prevention for cardiovascular disease: study protocol (the BALANCE program trial) Am Heart J. 2016;171:73–81. doi: 10.1016/j.ahj.2015.08.010.
    1. Stefler D, Pikhart H, Jankovic N, Kubinova R, Pajak A, Malyutina S, et al. Healthy diet indicator and mortality in eastern European populations: prospective evidence from the HAPIEE cohort. Eur J Clin Nutr. 2014;68:1346–1352. doi: 10.1038/ejcn.2014.134.
    1. Bach A, Serra-Majem L, Carrasco JL, Roman B, Ngo J, Bertomeu I, et al. The use of indexes evaluating the adherence to the Mediterranean diet in epidemiological studies: a review. Public Health Nutr. 2006;9:132–146. doi: 10.1079/PHN2005936.
    1. Fung TT, Chiuve SE, McCullough ML, Rexrode KM, Logroscino G, Hu FB. Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women. Arch Intern Med. 2008;168:713–720. doi: 10.1001/archinte.168.7.713.
    1. Roy R, Hebden L, Rangan A, Allman-Farinelli M. The development, application, and validation of a healthy eating index for Australian adults (HEIFA-2013) Nutrition. 2016;32:432–440. doi: 10.1016/j.nut.2015.10.006.
    1. Drake I, Gullberg B, Ericson U, Sonestedt E, Nilsson J, Wallström P, et al. Development of a diet quality index assessing adherence to the Swedish nutrition recommendations and dietary guidelines in the Malmö diet and Cancer cohort. Public Health Nutr. 2011;14:835–845. doi: 10.1017/S1368980010003848.
    1. McCullough ML, Feskanich D, Stampfer MJ, Giovannucci EL, Rimm EB, Hu FB, et al. Diet quality and major chronic disease risk in men and women: moving toward improved dietary guidance. Am J Clin Nutr. 2002;76:1261–1271. doi: 10.1093/ajcn/76.6.1261.
    1. 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;88:324–332. doi: 10.1093/ajcn/88.2.324.
    1. Weber B, Berwanger O, Costa RP, Lara EMS, Fernandes MBR, Ferreira ÂCB, et al. Álbum fotográfico de medidas e porções de alimentos. São Paulo: Instituto de Ensino e Pesquisa do Hospital do Coração; 2012.
    1. Nielsen SJ, Adair L. An alternative to dietary data exclusions. J Am Diet Assoc. 2007;107:792–799. doi: 10.1016/j.jada.2007.02.003.
    1. Physical status: the use and interpretation of anthropometry: report of a WHO Expert. Geneva: World Health Organization; 1995.
    1. Anales da 36ª Reunión del Comité Asesor de Investigaciones en salud. Encuesta multicentrica: salud, bien estar y envejecimiento (SABE) en América Latina y el Caribe.mayo 2001; Washington (DC): Wold Health Organization.
    1. Sociedade Brasileira de Cardiologia IV Diretriz da Sociedade Brasileira de Cardiologia sobre Tratamento do Infarto Agudo do Miocárdio com Supradesnível do Segmento ST. Arq Bras Cardiol. 2009;93(Suppl 2):179–264.
    1. Sociedade Brasileira de Hipertensão, Sociedade Brasileira de Cardiologia, Sociedade Brasileira de Endocrinologia e Metabologia et al. I Brazilian guidelines on diagnosis and treatment of metabolic syndrome. Arq Bras Cardiol. 2005;84(Suppl 1):1–28.
    1. Sociedade Brasileira de Cardiologia V Diretriz Brasileira Sobre Dislipidemias e Prevenção da Aterosclerose Departamento de Aterosclerose da Sociedade Brasileira de Cardiologia. Arq Bras Cardiol. 2013;101(Suppl1):1–22. doi: 10.5935/abc.2013s002.
    1. Sociedade Brasileira de Cardiologia, Sociedade Brasileira de Hipertensão, Sociedade Brasileira de Nefrologia VI Brazilian guidelines on hypertension. Arq Bras Cardiol. 2010;95(Suppl 1):1–51.
    1. Sociedade Brasileira de Diabetes . Diretrizes da Sociedade Brasileira de Diabetes (2015-2016) São Paulo: Sociedade Brasileira de Diabetes; 2016.
    1. Drewnowski A, Fulgoni VL. Nutrient density: principles and evaluation tools. Am J Clin Nutr. 2014;99(Suppl):1223–1228. doi: 10.3945/ajcn.113.073395.
    1. Miller PE, Cross AJ, Subar AF, Krebs-Smith SM, Park Y, Powell-Wiley T, et al. Comparison of 4 established DASH diet indexes: examining associations of index scores and colorectal cancer. Am J Clin Nutr. 2013;98:794–803. doi: 10.3945/ajcn.113.063602.
    1. Kennedy ET, Ohls J, Carlson S, Fleming K. The healthy eating index: design and applications. J Am Diet Assoc. 1995;95:1103–1108. doi: 10.1016/S0002-8223(95)00300-2.
    1. Panagiotakos DB, Pitsavos C, Stefanadis C. Dietary patterns: a mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk. Nutr Metab Cardiovasc Dis. 2006;16:559–568. doi: 10.1016/j.numecd.2005.08.006.
    1. Guenther PM, Kirkpatrick SI, Reedy J, Krebs-Smith SM, Buckman DW, Dodd KW, et al. The healthy eating Index-2010 is a valid and reliable measure of diet quality according to the 2010 dietary guidelines for Americans. J Nutr. 2014;144:399–407. doi: 10.3945/jn.113.183079.
    1. Najas M. I Consenso Brasileiro de Nutrição e Disfagia em Idosos Hospitalizados. Barueri, SP: Sociedade Brasileira de Geriatria e Gerontologia; 2011.
    1. Brasil, Ministério da Saúde. Vigitel Brazil 2014: protective and risk factors for chronic diseases by telephone survey. Brasília: Ministério da Saúde; 2015.
    1. Guenther PM, Reedy J, Krebs-Smith SM. Development of the healthy eating Index-2005. J Am Diet Assoc. 2008;108:1896–1901. doi: 10.1016/j.jada.2008.08.016.
    1. McNaughton SA, Ball K, Crawford D, Mishra GD. An index of diet and eating patterns is a valid measure of diet quality in an Australian population. J Nutr. 2008;138:86–93. doi: 10.1093/jn/138.1.86.
    1. Mendes A, Gavioli L, Previdelli AN, Fisberg RM, Marchioni DML. The diet quality index evaluates the adequacy of energy provided by dietary macronutrients. Revista de Nurição. 2015;28:7.
    1. de Andrade SC, Previdelli AN, Marchioni DML, Fisberg RM. Avaliação da confiabilidade e validade do Índice de Qualidade da Dieta Revisado. Rev Saude Publica. 2013;47:8.
    1. Fogli-Cawley JJ, Dwyer JT, Saltzman E, McCullough ML, Troy LM, Jacques PF. The 2005 dietary guidelines for Americans adherence index: development and application. J Nutr. 2006;136:2908–2915. doi: 10.1093/jn/136.11.2908.
    1. Schroder H, Fito M, Estruch R, Martinez-Gonzalez MA, Corella D, Salas-Salvado J, et al. A short screener is valid for assessing Mediterranean diet adherence among older Spanish men and women. J Nutr. 2011;141:1140–1145. doi: 10.3945/jn.110.135566.
    1. Schwingshackl L, Hoffmann G. Monounsaturated fatty acids, olive oil and health status: a systematic review and meta-analysis of cohort studies. Lipids Health Dis. 2014;13:154. doi: 10.1186/1476-511X-13-154.
    1. Estruch R, Ros E, Salas-Salvadó J, Covas MI, Corella D, Arós F, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med. 2013;368:1279–1290. doi: 10.1056/NEJMoa1200303.
    1. Alissa EM, Ferns GA. Functional foods and nutraceuticals in the primary prevention of cardiovascular diseases. J Nutr Metab. 2012; 10.1155/2012/569486.
    1. Bhupathiraju SN, Lichtenstein AH, Dawson-Hughes B, Tucker KL. Adherence index based on the AHA 2006 diet and lifestyle recommendations is associated with select cardiovascular disease risk factors in older Puerto Ricans. J Nutr. 2011;141:460–469. doi: 10.3945/jn.110.133603.
    1. Willett W. Nutritional epidemiology. 3. New York: Oxford University Press; 2012.

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