Artigos

Conteúdo (article):

Consumo de alimentos marcadores de uma alimentação saudável, segundo os grupos raciais de mulheres no Brasil
Consumption of food markers of a healthy diet according to racial groups of women in Brazil

Joana Furtado de Figueiredo Neta, joana.furtadof@gmail.com,
https://orcid.org/0000-0002-5246-921X 1
Samara Calixto Gomes, samaracalixto@alu.ufc.br,
https://orcid.org/0000-0002-7929-36481
Bruno Luciano Carneiro Alves de Oliveira, oliveira.bruno@ufma.br,
https://orcid.org/0000-0001-8053-79722
Thayná de Lima Sousa Henrique, thaylima8214@gmail.com,
https://orcid.org/0000-0002-1529-01731
Roberto Wagner Júnior Freire de Freitas, robertowjff@gmail.com,
https://orcid.org/0000-0001-9295-11773
Nirla Gomes Guedes, nirlagomes@hotmail.com,
https://orcid.org/0000-0003-0405-75171
Ana Karina Bezerra Pinheiro, ana_karina@ufc.br,
https://orcid.org/0000-0003-3837-41311
Marta Maria Coelho Damasceno, profamartamcdamasceno@gmail.com,
https://orcid.org/0000-0003-4461-0145 1

1Universidade Federal do Ceará – Fortaleza (CE), Brasil;
2Universidade Federal do Maranhão - Pinheiro (MA), Brasil;
3Fundação Oswaldo Cruz – Eusébio (CE), Brasil;

RESUMO

Objetivo: analisar o consumo de alimentos marcadores de uma alimentação saudável, segundo os grupos raciais de mulheres brasileiras entrevistadas na Pesquisa Nacional de Saúde 2019. Método: Estudo transversal com dados de 45.148 mulheres brancas e negras de ≥20 anos de idade. Os marcadores utilizados foram o consumo de frutas, verduras e legumes e feijão e peixe. A associação da cor/raça com os indicadores de consumo alimentar foi testada por regressão de Poisson bruta e ajustada para estimar Razões de Prevalência e Intervalo de Confiança de 95%. Resultado: A prevalência do consumo de frutas, verduras e legumes foi estatisticamente maior nas brancas, e o de peixes e feijão foi maior nas negras. Após o ajuste pelas variáveis socioeconômicas e demográficas, verificou-se que mulheres negras permaneceram apenas apresentando menores chances de consumir frutas (RP=0,91; 95% CI: 0,88-0,95) e somente maior de consumir feijão (RP=1,07; 95% CI: 1,04-1,10) do que às brancas. Conclusão: Verificaram-se desigualdades raciais para o consumo de alimentos saudáveis entre mulheres brasileiras, indicando que a cor/raça definiu um padrão alimentar para as mulheres negras que as colocam em condições vulneráveis em grande parte do consumo de frutas.

Descritores: Mulher. Raça. Saúde da população negra. Consumo alimentar.

ABSTRACT

Aim: To analyze the consumption of healthy food consumption markers, according to racial groups of Brazilian women interviewed in the 2019 National Health Survey (NHS). Methods: This work was a cross-sectional study with data from 45,148 white and black women, aged ≥20 years. The variables used were the consumption of fruits, vegetables and legumes, beans, and fish. The association between color/race and the dietary intake indicators was tested using crude Poisson Regression and adjusted to estimate Prevalence Ratios and 95% Confidence Intervals (95% CI). Results: The prevalence of the consumption of fruits and vegetables was statistically higher among white women, while fish and beans was higher among black women. After adjusting for socioeconomic and demographic variables, it was found that black women remained only less likely to consume fruit (PR=0.91; 95% CI: 0.88-0.95) and only more likely to consume beans (PR= 1.07; 95% CI: 1.04-1.10) than whites. Conclusion: There were racial inequalities for the consumption of healthy foods among Brazilian women, indicating that color/race defined a dietary pattern for black women that put them in vulnerable conditions in terms of fruit consumption.

Key-words: Women. Health of Ethnic Minorities. Food Consumption.

INTRODUCTION
Adequate and healthy eating has a protective role against Noncommunicable Diseases (NCDs), and promotes a greater quality of life and wellbeing. However, food consumption varies between racial groups of men and women. Around the world, there is an important debate about the determinants of eating habits and how inequalities associated with this food consumption can affect the living and health conditions of population groups. In Brazil, the National Health Promotion Policy (Política Nacional de Promoção da Saúde – PNPS) proposes the human right to adequate and healthy food as one of its priority themes, as a means of guaranteeing one’s quality of life, thereby reducing poverty and promoting a greater social inclusion1, 2.
In recent years, the Brazilian population has experienced several socioeconomic, demographic, epidemiological, and cultural changes that have resulted in changes in their health patterns and food consumption. Conversely, nutritional problems coexist and overlap in Brazil, such as food insecurity, overweight, and obesity3, 4.
The Ministry of Health points out that a total of 12,776,938 Brazilian adults monitored in Primary Health Care (PHC), by the Food and Nutrition Surveillance System (Sistema de Vigilância Alimentar e Nutricional – SISVAN) in 2019, 63% were overweight and 28.5% were obese. However, the frequency of obesity in women is higher than in men, 61.4% and 63.2% respectively5. In the black population, these data are no different, data from the 2018 Surveillance of Risk and Protective Factors for Chronic Diseases by Telephone Survey (Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico – Vigitel) indicate that the percentage of black adults who are overweight is 56.5% (57.3% among men and 55.8% among women) and 20% for obesity (21.8% among women and 18.1% among men)6. The main reason for the increasing prevalence of obesity and overweight in the world is the inability of food systems to provide healthy diets7.

As a result, there is a higher prevalence of NCDs in the black population, which indicates that risk factors are distributed differently according to color/race8. The black population practices less physical activity during leisure time and consumes less fruit and vegetables, which can be explained by lower income, less food availability, less opportunity, and less access to produced goods. On the other hand, they consume more foods that may have a greater relationship with local eating habits and a production or acquisition capacity, for example: beans and fish9.
Color/race can positively or negatively influence people’s eating patterns10. Racial inequalities in health in Brazil are deeply rooted; black and brown people have major disadvantages when compared to white people in different health-related outcomes11,12,13. In this sense, understanding color/race as one of the Social Determinants of Health (SDOH) presents a broader view in relation to the health-disease process, as it is related to other factors, including living conditions, socio-community wellbeing, income distribution, working conditions, social support networks, among others14.
Racial inequalities lead to less access to educational, socioeconomic, community, occupational resources and land, and consequently less social mobility. Most black people live in more economically segregated neighborhoods, where they are deprived of access to, commercialization of, and acquisition of healthy foods, coupled with less social and political capital, as well as less access to health services and guidance. They are also more commonly exposed to exhausting, unprofitable, and more stressful work11.
In Brazil, approximately half of the black population is represented by women. These suffer double discrimination: racism and sexism. Gender and racial discrimination interact and accumulate throughout life cycles, defining less healthy behaviors in black women when compared to white women15. All of these exposures restrict life and work options in less healthy environments, associated with greater adherence to risky behaviors that increase the risk of excess weight and a sedentary lifestyle, together with their associated problems16.
However, few studies have analyzed racial inequalities in the food consumption of Brazilian women at a national level according to socioeconomic, demographic, and state variables. Thus, the National Health Survey (NHS) represents an important source of data, as it enables the establishment of consistent measures of healthy eating for both white and black women, thus aiding in the implementation of more effective public policies throughout the country17.
Therefore, the present study sought to analyze healthy food consumption markers (beans, fish, fruits, and vegetables) according to the racial groups of Brazilian women interviewed in the 2019 NHS.

METHODS
Type of study
This is a cross-sectional study based on secondary data collected by the NHS, conducted in 2019. This data was used to analyze the consumption of beans, fish, fruits, vegetables, and legumes among Brazilian women.

The National Health Survey (NHS)
The NHS was conducted in 2019 by the Brazilian Institute of Geography and Statistics (IBGE) in partnership with the Ministry of Health (MS) and the Oswaldo Cruz Foundation (Fiocruz)17. This is a population-based household survey, conducted nationwide, seeking to obtain valid and representative information from the Brazilian population on a wide range of life and health measures.
The sampling used was probabilistic by means of conglomerates in three stages of selection, with stratification of the Basic Health Units (BHUs). The households represent the secondary units, while the tertiary unit represents the resident, aged ≥15 years, selected from each household based on the list of residents who respond to the individual part of the questionnaire applied by NHS 2019. The census sectors or set of sectors were initially selected by probability proportional to size for the Master Sample, and through an equally proportional probability for the NHS, households and residents were selected by simple random sampling17, 18.
Interviews were carried out in 94,115 households, in which 279,382 residents responded to the part of the questionnaire that was common for all individuals. By contrast, the questionnaire modules aimed at the specific resident, aged ≥15 years, were answered by a total of 94,115 people. However, for the analyses of the present study, only women ≥20 years of age, of white, brown, and black color/race were considered6. Thus, the final sample consisted of 45,148 individuals. Data collection took place between August 2019 and March 2020. Further methodological details can be obtained in NHS publications17, 18.

Outcome and independente variables
For this research, the socioeconomic, demographic, and health covariates were: female gender; age (in completed years); color/race (white, black (brown plus black); marital status (married, divorced, widow, single); education (in levels, up to incomplete elementary school or equivalent, incomplete high school or equivalent, incomplete higher education or equivalent, complete higher education); income level (up to 1/2 minimum wage (MW), 1/2 up to 1 MW, 1 to 2 MW, 2 to 3 MW, more than 3 MW); per capita household income quintile [in five strata: 1st (lowest), 2nd, 3rd, 4th, and 5th (highest)], with the median income in the 1st quintile being R$236.00, while in the 5th quintile it was greater than or equal to R$3,133.00; location of residence (urban, rural); macro-region of residence in five categories (North, Northeast, Midwest, Southeast, and South); location within the Brazilian state (capital, metropolitan region excluding capital, Interior); 26 states and the Federal District; possession of a private health plan (yes, no); number of residents in the household (grouped into three categories: 1, 2, and ≥ 3 people).
The following indicators of healthy eating were considered to be outcomes: recommended fruit consumption (on five or more days per week); vegetables (five or more days a week); regular consumption of beans (five or more days a week) and fish (at least once a week). The foods were chosen because they present a protective factor against the occurrence of overweight and obesity, as well as NCDs19.

Data analysis
The prevalence and their 95% confidence intervals (95% CI) of food consumption indicators by white and black color/race were estimated according to socioeconomic, demographic, and state variables. Differences in the distribution of frequencies of the estimated variables were considered statistically significant at the 5% level in the absence of any overlapping 95% CI.
Crude and adjusted Poisson regression analyses with robust variance were performed to estimate Prevalence Ratios (PR) and respective 95% CI for the association of race with each food consumption outcome.
All analyses were performed using the RStudio software, version 2022.2.3.492 (R Foundation for Statistical Computing, Boston, United States of America) and incorporate all of the characteristics of the NHS 2019 complex sampling plan.

Ethical aspects

The NHS 2019 data are of public domain and can be used according to the research of interest. The 2019 NHS project was previously approved by the National Research Ethics Commission (CONEP)/National Health Council (CNS) under opinion no. 3.529.37617.


RESULTS
In this study, data from 45,148 women (≥ 20 years) were evaluated, with a median age of 44 (32-58) years and a predominance of black women (55.3%; 95% CI: 54.4-56.2).
Figure 1 shows the prevalence of healthy food consumption markers in the total population of women and their racial groups. In the total population, the consumption of vegetables was more prevalent, while fish consumption was lower. The consumption of fruits and vegetables was statistically higher among white women, while the consumption of fish and beans was statistically higher among black women. In all categories, fish was the least consumed food (Figure 1).
Figure 2 shows the prevalence of healthy food consumption markers among adult women according to the Brazilian states. Statistically significant differences were observed in the greater consumption of vegetables among white women in the states of Maranhão and Mato Grosso, Espírito Santo, São Paulo, and Rio Grande do Sul. In relation to fruit consumption, a statistically significant prevalence among white women in the states of Pernambuco, Piauí, Mato Grosso do Sul, and in all states in the southeast and south regions of Brazil (Figure 2).
Figure 3 shows the prevalence of healthy food consumption markers of beans and fish among adult women according to the Brazilian states. The consumption of beans was found to be more prevalent among black women and was statistically significant for the states of Alagoas, Mato Grosso, Minas Gerais, Rio de Janeiro, São Paulo, Paraná, Rio Grande do Sul, and Santa Catarina. The highest consumption of fish was found among black women, which was statistically significant in the state of Amazonas for white women, and reached the highest levels in Paraná.
Most food consumption markers were low among younger people, regardless of race/color. It is important to note that in the age group over 60 years of age, white women consumed more vegetables (71.8%, CI: 69.9-73.7), fruits (70.1% 95% CI68.1-72.1), while among black women, the consumption of beans (70.3% 95% CI68.4-72.1) and fish (70.3% 95% CI68.4-72.1) were more prevalent.
Women who live alone tend to consume more vegetables, fruits, and fish than those who live with several people. White women who live alone eat more vegetables and fruits than do black women, while black women consume more beans and fish than do white women. In all racial groups, the highest proportion of healthy food consumption markers was among women with the highest educational levels and in the highest income quintile. The exception is the consumption of beans, which increased inversely proportional to these two factors: the lower the level of education and income, the greater the consumption. However, once again, black women consumed less vegetables and fruits and more beans and fish than did white women.
The Midwest region showed a higher prevalence of the consumption of vegetables (71.0% 95% CI68.1-73.9) and beans (51% 95% CI49.4-52.7) for white women. However, among black women, these items were consumed more in the Southeast region (64.3%; 95% CI 62.1-66.5, vegetables and 72.5%; 95% CI 70.5-74.4 for beans). Regarding the food consumption of fish, the North region showed the highest prevalence, which was higher among black women (75.5% 95% CI73.6-77.3) than among white women (69.7% 95% CI65.9-73.5).
Regarding the location of housing in the State, white women living in the capital and metropolitan region showed a higher consumption of fruits (60.8% 95% CI 59.2-62.5) and fish (51.0% 95% CI 49.4-52.7). For black women, the highest consumption in this region was vegetables (54.8% 95% CI 53.4-56.1), fruits (49% 95% CI 47.6-50.4), and fish (53% 95% CI 51.6-54.4). However, it was observed that white women, regardless of the type of city of residence in Brazil, consumed more fruits and vegetables, while black women only consumed more beans (Table 1).
Table 2 shows the PR and 95% CI for the Poisson regression. In the crude association, black women consume 18% (95% CI: 0.80-0.85) less vegetables and 21% (95% CI: 0.76-0.81) less fruit when compared to white women. On the other hand, black women had a 16% higher prevalence of the consumption of beans (95% CI: 1.13-1.19) and an 11% (95% CI: 1.07-1.15) higher prevalence of fish consumption than white women. After adjusting for socioeconomic and demographic variables (age group, number of residents, education, per capita income quintile, regions of the country, and location of the city of residence), the association of black women with fruit consumption continued to be negative (9% ; 95% CI: 0.88-0.95), while the consumption of beans (7%; 95% CI: 1.04-1.10) continued to be positive when compared to white women (Table 2).

DISCUSSION
The results of this study reveal racial inequalities in food consumption among black and white women across the country. White women showed a higher consumption of vegetables, legumes, and fruits, while black women presented a more prevalent consumption of beans and fish. Differences in this consumption pattern were verified between Brazilian states and socioeconomic and demographic characteristics of the women analyzed in this study. However, after the adjusted regression analysis, the results showed that black women continued to consume less fruit and more beans than white women.
Studies conducted in Brazil and other countries confirm that the quality of one’s diet tends to be better in the white population, influenced by increased income and/or education, and that diets with a high energy content and a low nutritional quality are more commonly consumed by vulnerable groups, such as the black population, who tend to opt for less healthy foods due to the price, the satiety they provide, the ease of access, and the level of knowledge they have about the health impact attributed to the inclusion of these items in their diet20, 21. A study that compared the eating patterns of white and black Americans showed that the eating pattern based on processed meat, fried foods, refined grains, sugar, margarine, sweets, and fats was more common among black people22, 23.
Data from the Ministry of Health confirm a high consumption of fruits and vegetables in the white as compared to the black population. Vigitel research reveals that while 39% of white people consume these foods at least five days a week, the percentage is only 29% in the black population. Moreover, the low consumption of fresh foods is a risk factor for several chronic diseases6.
Healthy eating patterns of women in this study increased with age, especially those over 50 years of age. This fact may be associated with the culture of greater care for health and food quality among older women, who historically occupy a social role as caregivers and are generally responsible for the selection and preparation of food, which can contribute to a greater care with one’s own diet20. Another hypothesis is that, with increasing age, there is a greater prevalence of NCDs and a greater demand for health services; thus, these women would be more likely to receive guidance on health care and nutrition, which would reflect on more healthy eating habits.
In all categories, fish was the food least consumed by the women in the study. Data from the National Food Survey (Inquérito Nacional de Alimentação – INA), between the years 2008-2009 and 2017-2018, revealed that there was a worsening in the quality of Brazilian food, showing a decrease in the consumption of beans and fish, giving space for a greater consumption of ultra-processed foods24.
Explanations for the reduction in fruit and vegetable consumption among black women can be attributed to the fact that the consumption of these foods is directly influenced by availability, price and purchasing power, so that, in general, individuals from a higher income bracket spend more with food and buy more fruits and vegetables25.
The results of this study indicate that black women show a weaker pattern of healthy food consumption markers when compared to white women, only surpassing white women in the consumption of beans. Considered one of the most traditional foods on the Brazilian menu, consumed mainly in the diet of individuals due to a low socioeconomic status during the Brazilian colonial period and because of its low price21. International studies attribute racial differences in dietary patterns to socioeconomic inequalities. Research shows that there is a higher cost of healthy foods (fruits and vegetables) and, therefore, a greater chance of their consumption by individuals with a better social position, generally observed among the white race, while other groups tend to consume foods linked to cultural identity26.
Food consumption in Brazil is quite diverse, depending on the region, culture, and customs18. The present study confirmed the different food consumption profiles that characterize the five macroregions of the country. The North macroregion stood out for the highest prevalence of regular fish consumption, while the Midwest stood out for the consumption of fruits, vegetables, and legumes, and the Southeast for high bean consumption. Such regional differences in the distribution of dietary markers are corroborated by a previous analysis based on 2013 NHS data, where the prevalence of these dietary markers was confirmed in these Brazilian regions27.
The II VIGISAN identified that, at the beginning of 2022, in the context of the COVID-19 pandemic, the proportion of food insecurity was higher in households whose main breadwinners identified themselves as black or mixed race. The results also showed a 70% increase in hunger among the black population in less than two years28. Despite the different population and social context, in the United States, one study identified that 30% of the native black population were food insecure, while this situation was found in only 10% of the native white population29.
Although the results are of great importance for the development of actions to promote and prevent women\'s health, this study does have some limitations. This is a cross-sectional study, and the food consumption data analyzed herein were from selected residents of the household and not from all other residents. The answers may also be influenced by the cognitive capacity related to the memory of these interviewees. Another limitation was in relation to the categorization of this food consumption, in which it was not possible to evaluate the number of portions consumed and their frequency. Despite these limitations, NHS data are representative of the Brazilian adult female population and enable the identification of healthy eating behavior patterns and their racial inequalities in Brazil, especially for foods that are most frequently consumed by the country\'s population.
Therefore, our findings verified racial inequalities in healthy food consumption markers among Brazilian women, showing important differences according to socioeconomic, demographic, and state characteristics. Color/race also defined a dietary pattern for black women, which places them in vulnerable conditions when it comes to fruit consumption but in favorable conditions when it comes to beans.
When considering the precarious living and health conditions that characterize this marginalized population, it is recommended that intersectoral actions be designed and implemented in order to promote healthy lifestyles that contribute to a decrease in body weight and improvements in nutrition among black women, thus diminishing inequalities throughout Brazil.
Race and gender, as social constructs, determine that black women are among the most vulnerable. The present study illustrates the need to understand socioeconomic inequalities and their consequences, such as possible impacts on healthy diets among the Brazilian female population.
Furthermore, the results indicate that the food consumption of Brazilian women presents discrepancies in relation to healthy eating guidelines, which highlights a need for educational and health promotion actions focused on gender and race.
Acknowledgments: To the National Council for Scientific and Technological Development (CNPq, Universal Announcement) for the productivity grant received by Ana Karina Bezerra Pinheiro and the post-doctoral grant received by Bruno Luciano C. A. de Oliveira; to the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Financing Code 001; and to the UFMA Postgraduate Nursing Program. This work was conducted with support from Announcement no. 21/2018-Procad/Amazônia.

REFERENCES

1. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Política Nacional de Promoção da Saúde (PNPS) - Anexo I da Portaria de Consolidação nº 2, de 28 de setembro de 2017, que consolida as normas sobre as políticas nacionais de saúde do SUS. Brasília: Ministério da Saúde [Internet]. 2018 [acessado em 18 nov. 2022]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_promocao_saude.pdf

2. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Política Nacional de Promoção da Saúde: 3 ed. Brasília: Ministério da Saúde [Internet]. 2010 [acessado em 19 nov. 2022]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_promocao_saude_3ed.pdf

3. Nogueira MBH, Pereira SCL, Carrara VA. National Food and nutrition policy in the fight against hunger generated by food empires. Rev. Katálysis 2022; 25(3): 507-516. https://doi.org/10.1590/1982-0259.2022.e86278

4. Canella DS, Bandeira L, Oliveira ML, Castro S, Pereira AS, Bandoni DH, Castro IRR. Update of the acquisition parameters of the Brazilian National School Feeding Program based on the Dietary Guidelines for the Brazilian Population. Cad. Saúde Pública 2021; 37(Sup 1): e00151420. https://doi.org/10.1590/0102-311x00151420

5. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Situação alimentar e nutricional no Brasil: excesso de peso e obesidade da população adulta na Atenção Primária à Saúde. Brasília: Ministério da Saúde [Internet]. 2020 [acessado em 16 nov. 2022]. Disponível em: https://aps.saude.gov.br/biblioteca/visualizar/MjAwNA==

6. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Análise em Saúde e Vigilância de Doenças não Transmissíveis. Vigitel Brasil 2018: população negra: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas para a população negra nas capitais dos 26 estados brasileiros e no Distrito Federal em 2018. Brasília: Ministério da Saúde [Internet]. 2019 [acessado em 16 nov. 2022]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/vigitel_brasil_2018_populacao_negra.pdf

7. Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, Brinsden H, Calvillo A, Schutter O, Devarajan R, Ezzati M, Friel S, Goenka S, Hammond RA, Hastings G, Hawkes C, Herrero M, Hovmand PS, Howden M, Jaacks LM, Kapetanaki AB, Kasman M, Kuhnlein HV, Kumanyika SK, Larijani B, Lobstein T, Long MW, Matsudo VKR, Mills SDH, Morgan G, Morshed A, Nece PM, Pan A, Patterson DW, Sacks G, Shekar M, Simmons GL, Smit W, Tootee A, Vandevijvere S, Waterlander WE, Wolfenden L, Dietz WH. The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. The Lancet 2019; 393(10173): 791–846. https://doi.org/10.1016/S0140-6736(18)32822-8

8. Santos KMR. Simultaneidade de comportamentos de riscos à saúde em adolescentes brasileiros de acordo com a raça/cor da pele [dissertação de mestrado]. Santa Cruz: Faculdade de Ciências da Saúde do Trairi (UFRN); 2022.
9. Malta DC, Moura L, Bernal RTI. Diferenciais dos fatores de risco de Doenças Crônicas não Transmissíveis na perspectiva de raça/cor. Ciência & Saúde Coletiva 2015; 20(3): 713-725. https://doi.org/10.1590/1413-81232015203.16182014

10. Brasil. Ministério da Saúde. Secretaria de atenção à Saúde. Departamento de Atenção Básica. Guia Alimentar para a População Brasileira. 2ª ed. 1ª reimpr. Brasília: Ministério da Saúde [Internet]. 2014 [acessado em 21 nov. 2022]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/guia_alimentar_populacao_brasileira_2ed.pdf

11. Camelo LV, Coelho CG, Chor D, Griep RH, Almeida MCC, Giatti L, Barreto SM. Racismo e iniquidade racial na autoavaliação de saúde ruim: o papel da mobilidade social intergeracional no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). Cad. Saúde Pública 2022; 38(1): e00341920. https://doi.org/10.1590/0102-311X000341920

12. SzwarcwaldI CL, Damacena GN, Souza Júnior PRB, Almeida WS, Lima LTM, Malta DC, Stopa SR, Vieira MLFP, Pereira CA. Determinantes da autoavaliação de saúde no Brasil e a influência dos comportamentos saudáveis: resultados da Pesquisa Nacional de Saúde, 2013. Revista Brasileira de Epidemiologia 2015; 18 (Suppl 2): 33-44. https://doi.org/10.1590/1980-5497201500060004

13. Chiavegatto Filho ADP, Laurenti R. Disparidades étnico-raciais em saúde autoavaliada: análise multinível de 2.697 indivíduos residentes em 145 municípios brasileiros. Cad. Saúde Pública 2013; 29(8):1572-1582. https://doi.org/10.1590/0102-311X00139012
14. Galvão ALM, Oliveira E, Germani ANCG, Luiz OC. Determinantes afetados da saúde, raça, gênero e classe social: uma revisão de escopo. Saúde e Sociedade 2021; 30(2): e200743. https://doi.org/10.1590/S0104-12902021200743

15. Organização Mundial da Saúde. Conferência mundial sobre Determinantes sociais. Diminuindo diferenças: a prática das políticas sobre determinantes sociais da saúde [Internet]. 2011 [acessado em 20 nov. 2022]. Disponível em: https://SDOHbr.ensp.fiocruz.br/wp-content/uploads/2020/10/Documento-Tecnico-da-Conferencia-vers%C3%A3o-final.pdf

16. Krieger N. Discrimination and Health Inequities. International Journal of Health Services 2014; 44(4): 643-710. https://doi.org/10.2190/HS.44.4.b

17. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, Sardinha LMV, Macário EM. National Health Survey 2019: history, methods and perspectives. Epidemiol. Serv. Saude 2020; 29(5): e2020315. https://doi.org/10.1590/S1679-49742020000500004. Errata em: Epidemiol. Serv. Saude 2021; 30(3):e2021830. https://doi.org/10.1590/S1679-49742021000300031

18. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: IBGE [Internet]. 2020 [acessado em 20 nov. 2022]. Disponível em: https://www.NHS.icict.fiocruz.br/wp-content/uploads/2021/02/liv101764.pdf

19. Camilo VMA, Santana JM, Freitas F, Silva IMM, Oliveira FS, Campiolo S. Padrões de consumo alimentar em uma cidade do Recôncavo da Bahia: um enfoque na segurança alimentar e nutricional. Mundo da Saúde 2016; 40(1): 51-60. https:// doi: 10.15343/0104-7809.201640015160

20. Medina LPB, Barros MBA, Sousa NFS, Bastos TF, Lima MG, SzwarcwaldI CL. Desigualdades sociais no perfil de consumo de alimentos da população
brasileira: Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2019; 22 (Suppl 2): e190011. https://doi.org/10.1590/1980-549720190011.supl.2

21. Canuto R, Fanton M, Lira PIC. Iniquidades sociais no consumo alimentar no Brasil: uma revisão crítica dos inquéritos nacionais. Ciência & Saúde Coletiva 2019; 24(9): 3193-3212. https://doi.org/10.1590/1413-81232018249.26202017

22. Judd SE, Gutiérrez OM, Newby PK, Howard G, Howard VJ, Locher JL, Kissela BM, Shikany JM. Dietary patterns are associated with incident stroke and contribute to excess risk of stroke in black Americans. Stroke 2013;44(12): 3305-11. https://doi.org/10.1161/STROKEAHA.113.002636

23. Hiza HAB, Casavale KO, Guenther PM, Davis CA. Diet quality of Americans differs by age, sex, race/ethnicity, income, and education level. J Acad Nutr Diet. 2013; 113(2): 297-306. https://doi.org/10.1016/j.jand.2012.08.011

24. Domene SMA, Barata RB. Inquéritos Nacionais de Alimentação: consumo alimentar e muito mais. Rev Saude Publica 2021; 55 (Supl 1):1s. https://doi.org/10.11606/s1518-8787.2021055supl1ed

25. Santos GMGC, Silva AMR, Carvalho WO, Rech CR, Loch MR. Perceived barriers for the consumption of fruits and vegetables in Brazilian adults. Ciência & Saúde Coletiva 2019; 24(7): 2461-2470. https://doi.org/10.1590/1413-81232018247.19992017

26. Dekker LH, Nicolaou M, Dam RMV, Vries JHM, Boer EJ, Brants HAM, Beukers MH, Snijder MB, Stronks K. Socio-economic status and ethnicity are independently associatedwith dietary patterns: the HELIUS-Dietary Patterns study. Food & Nutrition Research 2015; 59: 26317. https://doi.org/10.3402/fnr.v59.26317

27. Jaime PC, Stopa SR, Oliveira TP, Vieira ML, Szwarcwald CL, Malta DC. Prevalência e distribuição sociodemográfica de marcadores de alimentação saudável, Pesquisa Nacional de Saúde, Brasil 2013. Epidemiol. Serv. Saúde 2015; 24(2): 267-276. https://doi.org/10.5123/S1679-49742015000200009

28. Rede Brasileira de Pesquisa em Soberania e Segurança Alimentar e Nutricional – Rede PENSSAN. II Inquérito Nacional sobre Insegurança Alimentar no
Contexto da Pandemia da COVID-19 no Brasil: Rede PENSSAN [Internet]. 2022 [acessado em 7 nov. 2022]. Disponível em: https://static.poder360.com.br/2022/06/seguranca-alimentar-covid-8jun-2022.pdf

29. Myers AM, Painter MA. Food insecurity in the United States of America: an examination of race/ethnicity and nativity. Food Security: The Science, Sociology and Economics of Food Production and Access to Food; 9(6): 1419-1432. https://doi.org/10.1007/s12571-017-0733-8

30. Cisne M, Santos SMM. Feminismo, diversidade sexual e Serviço Social. 1ª ed. São Paulo: Cortez Editora; 2018.

31. Graham E, Dallmann D, Melgar-Quiñonez H. Gender disparities in perceived life satisfaction within food insecure populations. Food Security: The Science, Sociology and Economics of Food Production and Access to Food 2019; 11(3): 493-502. https://doi.org/10.1007/s12571-019-00932-z