Artigos

Conteúdo (article):

FATORES ASSOCIADOS AO CONSUMO DE AÇÚCARES DE ADIÇÃO DE IDOSOS DA REGIÃO DE CAMPINAS – SP

FACTORS ASSOCIATED WITH ADDED SUGAR CONSUMPTION OF OLDER ADULTS FROM THE REGION OF CAMPINAS – SP

AUTORES
José Nilton Boaventura da Silva Júnior, Universidade Estadual de Campinas, niltonjunior-boaventura@hotmail.com, https://orcid.org/0000-0003-2754-2750.
Carolina Neves Freiria, Universidade Estadual de Campinas, carol_freiria@hotmail.com, https://orcid.org/0000-0002-1493-3202
Graziele Maria da Silva, Universidade Estadual de Campinas, gramsilva9@gmail.com, https://orcid.org/0000-0003-0634-275X
Ligiana Pires Corona, Universidade Estadual de Campinas, ligiana.corona@fca.unicamp.br, https://orcid.org/0000-0001-5298-7714

RESUMO
A alimentação adequada tem profundo impacto na saúde dos idosos, e uma especial atenção deve ser dada ao consumo de açúcares de adição na dieta, que em excesso está associado a pior controle das doenças crônicas nesta fase. O objetivo do estudo foi avaliar a prevalência do consumo de açúcares de adição de idosos da região de Campinas-SP, seus fatores associados e suas principais fontes alimentares. Trata-se de estudo transversal realizado na região de Campinas-SP, com amostra de conveniência de 586 idosos. O consumo foi obtido por meio de dois recordatórios de 24 horas, sendo inadequado se >5% do consumo energético total. Também foi calculada a contribuição dos alimentos em relação ao teor total de açúcares. Considerou-se nível crítico de p<0,05. O consumo médio de açúcares de adição estava acima do recomendado (7,0%), inadequado em mais da metade da população estudada, sendo o açúcar de mesa e o mel as principais fontes dietéticas. A prevalência de inadequação do consumo foi maior entre mulheres (69,8%; p=0,004) e em indivíduos com baixo peso (83,7%; p=0,014), e o consumo foi menor em portadores de diabetes (47,8%; p<0,001). Os resultados apontam para que sejam elaboradas ações de saúde e nutrição a fim de garantir um consumo adequado de açúcares nesta fase.
Palavras-chave: Idoso; Consumo alimentar; Açúcar; Ingestão Diária Recomendada; Alimentos Ultraprocessados.

ABSTRACT
Adequate nutrition has a profound impact on older adults\' health. Therefore, special attention should be given to the dietetic intake of added sugars, which in excess is associated with poorer control of chronic diseases in this phase. The aim of the study was to evaluate the prevalence of consumption of added sugars in older adults in the Campinas-SP region, its associated factors, and its main dietary sources. A cross-sectional study was conducted in the region of Campinas-SP, with a convenience sample of 586 older individuals. Intake was obtained using two 24-hour food recalls, and values >5% of total energy consumption were considered inadequate. The contribution of the groups and foods in relation to the total content of sugars was also calculated. A critical level of p<0.05 was considered. The average intake of added sugars was higher than recommended (7.0%), and this inadequacy was observed in more than half of the sample, being table sugar and honey the main dietary sources. The prevalence of inadequate consumption was higher among women (69.8%; p=0.004) and individuals with low weight (83.7%; p=0.014), and lower in those with diabetes (47.8%; p<0.001). Results indicate that health and nutrition actions should be developed to ensure adequate sugar intake at this stage.
Keywords: Older adults; Food consumption; Sugar; Recommended Dietary Allowances; Ultra-Processed Foods.

INTRODUCTION
Brazil is undergoing an accelerated populational aging process due to epidemiological transitions in recent years. This is driven mainly by the complex change in health standards and disease, which are related to the decrease in mortality due to infectious diseases and increasing in noncommunicable diseases rates 1. Currently, chronic noncommunicable diseases (CNCDs) are the main morbidity and mortality causes in the country, representing 74% of deaths in Brazil in 2016 2,3. It is estimated that 39.5% of older Brazilians have some type of chronic disease, and almost 30% have two or more associated diseases 4.
Current Western dietary pattern is one of the main factors associated with the development of chronic diseases. It is marked by high consumption of foods rich in fats, salt, and sugar, with low nutritional density, usually from ultra-processed foods 5,6.
Regarding sugar, the term “added sugars” is used as a reference to a class of simple carbohydrates extracted from foods - such as sugarcane, corn, and honey - to be later used in preparations and processed foods. They are mainly composed of monosaccharides - glucose, fructose and galactose, and disaccharides - such as sucrose and lactose 7. The World Health Organization recommends that its consumption should represent less than 5% of daily caloric intake 8. Dietary guide for the Brazilian population highlights the necessity to avoid ultra-processed foods and sweetened beverages consumption (such as soft drinks, industrialized juices and sweets) since they contain large amounts of added sugars in their composition 9.
Older adults present an increased risk factor for CNCDs development due to the aging process itself. Also, they may have a natural loss of food flavors perception, which may compromise their nutritional status. That’s because it implies a greater addition of sugar in preparations to enhance a taste that pleases the palate, leading to exaggeration in its quantity 10.
Considering that older adults are a population at risk for developing CNCDs and there are few studies in Brazil that evaluate their food consumption, especially in relation to sugars, it is important to investigate the prevalence of consumption of added sugars in older adults’ diets and their associated factors to evaluate their consumption and allow development of more effective future public policies for this group.
In this sense, the objective of the present study is to evaluate the prevalence of consumption of added sugars in the diet of older adults in the region of Campinas-SP, their main dietary sources, and their associated factors.
METHODS
Sample
The project used the database of the study “Evaluation of the prevalence of micronutrient deficiency among community-dwelling older adults in the metropolitan area of Campinas – SP” conducted between 2018 and 2019 in the cities of Campinas, Limeira, and Piracicaba. Participants were asked to answer a questionnaire containing socioeconomic, health, lifestyle, and nutritional questions. Anthropometric evaluation and blood sample collection were also performed. Details on the sample size and collection procedures can be found in the work of Rolizola et al. 11. The research project was funded by the National Council for Research and Development (CNPq) under process number 408262/2017-6 and approved by the ethics committee under protocol CAAE 95607018.8.0000.5404.
The following main research inclusion criteria were adopted: being 60 years of age or older, having agreed to participate in the study by signing the informed consent form (ICF), being a resident of one of the previous selected cities, being registered in the Family Health Strategy (FHS). Also, they should present minimal ability to understand study procedures and consent form with no need for an auxiliary informant. The exclusion criteria were: use of food supplements based on vitamins and/or minerals (since the main study aimed to assess the deficiency of some of these nutrients and their dietary consumption, not considering supplement usage), and being undergoing chemotherapy treatment or monitored by a home care program, since these conditions significantly alter food consumption.
From the total number of participants in the main study (n = 611), 19 who did not have complete food consumption data and 6 individuals who did not answer the socioeconomic questionnaire were excluded, totaling a final sample of 586 participants.
Instruments and study variables
24-hour recall (24HR) was used to evaluate older adults’ food consumption. The tool is based on list and quantify all foods and beverages consumed on the day before the interview. This method was chosen because of its fast and easy applicability, it does not alter food intake, and participant does not need to be literate 12.
Several methodological precautions were taken to minimize possible biases in food consumption assessment. All 24HR applicators were previously trained and qualified in the proper execution of the instrument, following recommended steps to perform it, which helped to minimize participants’ memory bias. 24HR was applied on the day of research data collection, being reapplied via telephone between 20 and 30 days after first application, to obtain usual feeding variation. Personal or telephone data was not collected on Mondays to avoid collect Sunday consumption, which tends to be atypical. In the first 24HR, conducted personally, photos of portions and utensils were used to assist portion size estimation. At this moment, the participant received a material with the main household measures used to take home and serve as support in carrying out the second 24HR to minimize measurement bias.
Nutrition Data System for Research (NDRS) software was used to quantify nutritional value from foods consumed at 24HR 13. To estimate usual added sugars intake, Multiple Source Method (MSM) was used, which is a statistical web-based modeling 14. This method is a mixed model composed of three parts, which requires at least two days of short-term dietary measures (such as 24 hours) in a random subsample from target population. In the first stage, consumption probability of a food/nutrient in a day is estimated by logistic regression with random effects (probability model). Then, all data transformed to normality is used to estimate usual nutrient amount intake on consumption days by linear regression, also with random effects (quantity model). Finally, usual individual intake is calculated by multiplying food/nutrient consumption probability (step 1) by usual food intake amount (step 2).
Selected variables for present study are described below:
Sociodemographic: gender (male, female); age group (<75 years, ≥75 years); marital status (with a partner, without a partner - considering single, divorced, and widowed); education (0 to 8 years, 9 years or more); ethnicity (Caucasians, African Americans and Mixed Race, Others - South native American and Asian); monthly income (≤2 minimum wages, > 2 minimum wages - considered the value reported at the time of the study: 2018 - R$ 954 15; 2019: R$ 998) 16.
Health: Body Mass Index -BMI (eutrophic, low weight, overweight - considering as cutoff points of the BMI those used by the Ministry of Health: low weight <22 kg/m², normal weight between 22 and 27 kg/m², and excess of weight> 27 kg/m² 17; self-reported diabetes mellitus (without disease, with disease); physical activity (active, not active - adopting as active those who practiced 150 minutes or more of activities in the week and nonactive those who practiced less than 150 minutes of activities in week 18); alcoholism (nonalcoholic, ex-alcoholic/alcoholic-being considered ex-alcoholic/alcoholic those who have ingested/ingest alcoholic beverage), smoking (no, ex-smoker/smoker).
Variable of interest: values obtained for added sugars intake were used by applying 24HR. Values recommended by the World Health Organization guidelines 8 were used to determine adequate intake, which suggests that simple sugars intake should be reduced to 5% of daily needs. In this case, individuals with sugar consumption rate above 5% of total calories consumed were considered with an inadequate sugar intake.
Foods ingested by participants in the first 24HR were coded and then organized into food groups or presented separately, considering their main sugar sources. This procedure was used to determine which foods/food groups most contributed to added sugar consumption in older adults’ diet. Foods/food groups that most contributed to total nutrients in the diet were selected. For relative contribution (RC) calculation of added sugars dietary sources, a method proposed by Block et al. 19 was applied by using equation: RC = (Total food sugar (g)/100 (Total dietary sugar (g)) x 100.
Statistical analysis
Sugar consumption mean values (with their respective standard deviations) were described in terms of sociodemographic and health variables. Shapiro-Wilk normality test showed that statistical distribution did not adhere to normality. Therefore, for mean values comparison between independent variables groups, non-parametric tests were used: Mann-Whitney test for comparisons between 2 categories and Kruskal-Wallis for comparisons between 3 categories.
For consumption inadequacy analysis, added sugars total amount was categorized into adequate and not adequate (>5% of total calories consumed), and raw odds ratios (OR) of sugar inadequate consumption were estimated in relation to selected variables using logistic regression method. All statistical analysis were performed using Stata® software version 12, with p<0.05 significance level.
RESULTS
Among participants, most were female (69%), aged between 60 and 74 years (78%), Caucasian (55%), with a partner (60%), with a family income of more than 2 minimum wages (68%) and education less than or equal to 8 years (72%). In addition, most of them were not physically active (53%) and overweight (60%). Data regarding sample characteristics are shown in Table 1.

Table 1

Regarding food intake, an added sugars intake average intake of 104 kcal (26 g) was observed, which represents, on average, 7.0% of ingested calories. Table 2 shows mean values of added sugar intake as a percentage of total caloric intake, according to independent variables. Sugar intake was statistically higher among older women and those without a partner. Lower intake values were found in diabetic individuals. There were no significant differences in added sugars intake in relation to age, education, ethnicity, monthly income, and physical activity.

Table 2

Regarding inadequacy prevalence, 66% of study population has a consumption of added sugars higher than 5% of total energy consumption of World Health Organization 13 indication. Table 3 shows inadequacy prevalence of sugar intake and odds ratio (with their respective confidence intervals – 95%) according to some selected characteristics. Regarding added sugars intake indication limited to 5% of daily caloric intake, higher inadequacy odds were found in females (OR: 1.70; p = 0.004) and underweight (OR: 2.78; p = 0.014). In contrast, diabetic individuals had lowest inadequacy odds (OR: 0.35; p <0.001).

Table 3

Regarding main dietary sources of added sugars to older adults’ diet evaluation, table sugar and honey were consumed in greatest amount (51% of all food sugars sources). Figure 1 shows main food sources of added sugars in relative contribution.

Figure 1

DISCUSSION
In our study, an added sugars intake average of approximately 7.0% of total energy percentage was found. This value is similar to those obtained in Consumer Expenditure Survey (Pesquisa de Orçamentos Familiares - POF) of 2017 and 2018, in which it was found that added sugar consumption for female and male individuals aged 60 years or older, on average, increased from 5.1% of daily energy consumption in 2008-2009 to 8.8% in 2017-2018 20.
Corroborating present study, Bueno et al 21, in a study that evaluated factors associated with added sugars intake in adults and older adults, indicated that daily energy average from added sugars among older adults was 8.4%. In contrast, this rate is higher than what was found in ANIBES study with individuals aged between 65 and 75 years (5.1%) conducted in Spain, which investigated sugar intake (added and intrinsic) in diet, according to gender and age group 22.
Regarding sugar intake inadequacy prevalence, 66% of older adults had inadequate intake in our study, values higher than those found in study conducted by Marinho et al. 23 that evaluated sugars intake and consumption determinants in a Portuguese national sample, where 36.1% of older adults showed inadequacy regarding 5% recommendation, as well as in Spanish population where rate inadequacy was 44.7% 24.
Regarding main dietary sources of added sugar, Bueno et al.21 also observed that among foods responsible for added sugar in older adults’ diet were table sugar, honey, and sweet and/or sweetened beverages. Together, they represent 70% of added sugars. In the Portuguese and Spanish populations, table sugar was also main dietary source, accounting for 30% and 25%, respectively, of added sugar intake in older adults’ diets 23,22. Conversely, among older adults in United States aged over 71 years, sweet bread (20.7%) and sweetened beverages (17.7%) were main dietary sources of added sugar, with this change from sweetened beverages to sweet baked products is explained as a reflection of a more peaceful eating routine that comes with retirement, either eating alone or meeting with other people for socialization 25.
There is also an important contribution of ultra-processed foods such as cookies, cakes, processed bread, and sausages for sugar consumption in older adults’ diet, representing approximately 15% of calories consumed. In 2017-2018’s Consumer Expenditure Survey (POF), prevalence of bread, cookies, cakes, and sausages consumption among older adults was, on average, 52.7%, 14.4%, 11.3%, and 1.6%, respectively. Among older adults, it is common to substitute main meals based on culinary preparations (especially dinner) for snacks made, for example, by bread, milk, cookies/biscuits, and other ultra-processed foods such as sausages and ham 20.
In this context, special attention should be given older adults’ diet, since ultra-processed food consumption, such as soft drinks, cookies, and treats, negatively influences food quality, increasing energy density, sugar levels, saturated and trans-fat and leading to reduced fiber levels, thus increasing risks of overweight, obesity, and mortality from cardiovascular diseases 26.
Considering analysis between groups, a higher sugar consumption and inadequacy rate were observed among women, that were 70% more likely to have inadequate consumption than men. These results were also evidenced by Bueno et al.21, where females had a higher sugar percentage in diet than males (8.7% and 7.8%, respectively).
In 2017-2018’s POF, Brazilian women also had a higher percentage of total caloric added sugars intake than men, 9.3% versus 8.3%, respectively 20. According to Ferreira and Magalhães 27, this situation can be explained by the inequality and social devaluation faced by Brazilian women, imposing an insufficient dietary pattern from the nutritional point of view, marked by reduced access to natural foods, such as vegetables and fruits, and increased choice of denser and cheaper foods, such as those rich in sugars.
In our study, it was also observed that participants without partners had a higher sugar contribution in their diet when compared to married individuals. According to Locher and Sharkey 28, living with a partner is consistently reported as an adequate predictor of nutritional health among older adults. Women, especially widows, may be vulnerable to nutritional problems because they do not have necessary financial resources for an adequate diet or present a lower diet desire to cook for themselves because they have no one to cook for. And thus they opt for more practical and hyper-palatable meals with higher sugar content.
It was also found that diabetic individuals had a lower added sugar intake and lower inadequacy rates. Several studies indicate that high sugar consumption can lead to the development of several diseases, such as obesity and diabetes mellitus 29.
Diabetic individuals often report difficulties in adhering to proposed diets due to various associated meanings and negative emotions, such as pleasure loss in eating associated with food restriction feeling. Although such practices as eliminating sugar or limiting consumption of foods containing carbohydrates are described much more frequently by diabetics as an important part of individual’s dietary for disease control 30. Similarly, in a study that researched an association between dietary quality and socioeconomic factors, health, and nutrition of older adults residents in the city of Viçosa-MG, a positive association was found between diabetes mellitus historic and “better diet quality”, although it was not evaluated whether older adults with better diet quality had adequate disease control 31.
Thus, even though diet adequacy process is difficult for older adults with diabetes, participants in our study showed greater attention to nutritional guidelines, at least in relation to sugar intake. These findings agree with results from a study conducted by Virtanen et al. 32 comparing male older adults’ diets with diabetic and nondiabetic men in Finland, Netherlands, and Italy. Results indicated that diabetic men ingested less added sugar than nondiabetic men in all three countries.
Regarding BMI, 83.7% of older adults with low weight had inadequate sugar intake. Aging anorexia is one of the main causes of inadequate food consumption, characterized by reduced appetite and low food intake, which can occur by decreasing energy demand. Older adults may have a lower physiological appetite, consume less food per meal and slowly, influencing early satiety and decreased daily energy intake, causing negative energy balance and, consequently, body weight loss. In addition, aging anorexia may be influenced by lower food palatability. This may motivate an overall reduction in food interest and a choice of less varied diets from a nutritional point of view, with an increase in more palatable foods with higher sugar amount 33.34.
Although in present study no association was found between added sugar intake and educational level and age, other studies indicated a higher sugar consumption among individuals with lower educational levels 31,35 and among older adults 36. Furthermore, despite dental prostheses usage, dysphagia and changes in taste are factors that may interfere with food preferences among older adults, in our study no significant differences were observed between these variables and average sugar consumption in population (not shown data).
Present study has some limitations that should be considered when interpreting its results. First, method used to assess food consumption (24HR) is susceptible to memory bias, which may be compromised among older adults interviewed, although all applicators were subjected to training and used photographic manuals at the time of interview to minimize possible errors. It is also important to mention that 24HR is a method that describes interviewee\'s current food consumption and may not be suitable for estimating habitual consumption. However, it is considered that this bias was minimized considering that: 1) foods (sugars) and portions estimation undergo less variation than specific nutrients, especially micronutrients; 2) older adults tend to have a monotonous diet most of the time, with little variation between days 37; 3) in literature, it is stated that if sample is large enough, as the one studied here, even a single day of consumption per individual can be used to estimate usual population average consumption, eliminating extreme values due to population distribution, and, to estimate the intra-individual daily variation, it is usually statistically more efficient to increase the number of individuals in sample than to increase number of days above 2 days per individual 38,39; and 4) usual consumption adjustment method used (MSM) is developed exactly to estimate usual consumption from a limited number of records.
In addition, this is a cross-sectional study, and it is not possible to search for cause-and-effect relationships. However, it is an important method to verify population data, as it can generate hypotheses, possible associated factors, and guide future longitudinal research and/or proposals for intervention. Besides that, studied population is community-dwelling older adults, and it is not possible to generalize results observed here to other populations.
CONCLUSION
The present work presented relevant results that characterized and quantified eating behavior of older adults with a focus on added sugars intake, showing that older adults had a consumption of added sugars above recommended. This consumption is higher among women, in individuals without a partner and with low weight, and lower in people with diabetes. Furthermore, it was observed that among main dietary sources were table sugar and honey. Thus, it was evidenced that socioeconomic and health factors are determinants in food quality and in added sugars intake by older adults, showing the importance of studies on food consumption in this group as a way of identifying main factors associated with inadequacy and expanding the knowledge about their eating habits. These findings can help in new guidelines formulation, nutritional strategies, and interventions, both at the individual level and in public policies, aimed at ensuring an improvement in the food quality of this population, which has highest rates in prevalence of CNCDs.

REFERENCES
1. Lebrão ML. O envelhecimento no Brasil: aspectos da transição demográfica e epidemiológica. Saude Col 2007; v. 4, n. 17, p. 135-140.
2. Ramos LR, Tavares NUL, Bertoldi AD, Farias MR, Oliveira MA, Luiza VL, Pizzol TSD, Arrais PSD, Mengue SS. Polifarmácia e polimorbidade em idosos no Brasil: um desafio em saúde pública. Rev Saude Pub 2016; v. 50, suppl 2, 9 s.
3. World Health Organization (WHO). Noncommunicable Diseases (NCD) Country Profiles, 2018. Geneva: WHO; 2018.
4. Sociedade Brasileira De Geriatria e Gerontologia (SBGG) [Internet]. OMS divulga metas para 2019; desafios impactam a vida de idosos. Brasil: SBGG; 2019. Disponível em: . Acesso em: 17 ago. 2021.
5. Batal M, Steinhouse, L, Delisle H. The nutrition transition and the double burden of malnutrition. Med Sante Trop 2018. 28(4):345-350.
6. Ministério da Saúde. Marco de Referência da Vigilância Alimentar e Nutricional na Atenção Básica. Brasília: Secretaria de Atenção à Saúde. Departamento de Atenção Básica; 2015.
7. Levy RB, Claro, RM, Bandoni DH, Mondini L, Monteiro, CA. Disponibilidade de “açúcares de adição” no Brasil: distribuição, fontes alimentares e tendência temporal. Rev Bra Epidem 2012; v. 15, ed. 1, p. 3-12.
8. World Health Organization (WHO). Guideline: Sugars intake for adults and children. Geneva: WHO; 2015.
9. Ministério da Saúde. Fascículo 2 Protocolos de uso do Guia Alimentar para a população brasileira na orientação alimentar da população idosa. Brasília: Ministério da Saúde, Universidade de São Paulo; 2021.
10. Ministério da Saúde. Alimentação saudável para a pessoa idosa: um manual para profissionais de saúde. Brasília: Secretaria de Atenção à Saúde. Departamento de Atenção Básica, 2009.
11. Rolizola PMD, Freiria CN, Silva GM, de Brito TRP, Borim FSA, Corona LP. Insuficiência de vitamina D e fatores associados: um estudo com idosos assistidos por serviços de atenção básica à saúde. Cien Saude Colet [serial on the Internet]. 2021 Jan. [Cited 2021 Aug 24]. Avaiable from: http://www.cienciaesaudecoletiva.com.br/artigos/insuficiencia-de-vitamina-d-e-fatores-associados-um-estudo-com-idosos-assistidos-por-servicos-de-atencao-basica-a-saude/17915?id=17915.
12. Fisberg RM, Colucci ACA. Inquéritos Alimentares: Métodos e Bases Científicas. In: Waitzberg DL, organizador. Nutrição oral, enteral e parenteral na prática clinica. São Paulo: Atheneu; 2009. p 373-383.
13. University of Minnesota. NDSR Software [computer program]. Minnesota: Nutrition Coordinating Center (NCC); 2018. Disponível em: . Acesso em: 18 ago. 2021.
14. Harttig U, Haubrock J, Knüppel S; Boeing H. The MSM program: web-based statistics package for estimating usual dietary intake using the multiple source method. Eur J Clin Nutr 2011; 65 Suppl 1:S87–91.
15. Brasil. decreto n° 9.255, de 29 de dezembro de 2017. Regulamenta a Lei n° 13.152, de 29 de julho de 2015, que dispõe sobre o valor do salário mínimo e a sua política de valorização de longo prazo. Diário Oficial da União 2017; 29 dez.
16. Brasil. Decreto n° 9.661, de 1° de janeiro de 2019. Regulamenta a Lei n° 13.152, de 29 de julho de 2015, que dispõe sobre o valor do salário mínimo e a sua política de valorização de longo prazo. Diário Oficial da União 2019; 01 jan.
17. Ministério da Saúde. Caderneta de saúde da pessoa idosa. Brasília: Secretaria de atenção à saúde. Departamento de ações programáticas estratégicas, 2017.
18. World Health Organization (WHO). Global recommendations on physical activity for health. Geneva: WHO; 2010.
19. Block G, Hartman AM, Dresser CM, Carroll MD, Gannon J, Gardner L. A data-based approach to diet questionnaire design and testing. Am J Epidemiol 1986; 124:453-69.
20. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de Orçamentos Familiares 2017-2018: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2020.
21. Bueno MP, Marchioni DML, César CLG, Fisberg RM. Added sugars: consumption and associated factors among adults and the elderly. Rev Bras Epidemiol 2012. v. 15, ed. 2, p. 256-264.
22. Ruiz E, Rodriguez P, Valero T, Ávila JM, Aranceta-Bartrina J, Gil Á, González-Gross M, Ortega RM, Serra-Majem L, Varela-Moreiras G. Dietary Intake of Individual (Free and Intrinsic) Sugars and Food Sources in the Spanish Population: Findings from the ANIBES Study. Nutrients 2017; 9(3):275.
23. Marinho AR, Severo M, Correia D, Lobato L, Vilela S, Oliveira A, Ramos E, Torres D, Lopes C. Total, added and free sugar intakes, dietary sources and determinants of consumption in Portugal: The National Food, Nutrition and Physical Activity Survey (IAN-AF 2015–2016). Pub Health Nutrition 2019; 23(5), 869-881.
24. Ruiz E, Varela-Moreiras G. Adequacy of the dietary intake of total and added sugars in the Spanish diet to the recommendations: ANIBES study. Nutr Hosp 2017; 34(Suppl 4):45-52.
25. Ricciuto L, Fulgoni 3rd VL, Gaine PC, Scott MO, DiFrancesco L. Sources of Added Sugars Intake Among the U.S. Population: Analysis by Selected Sociodemographic Factors Using the National Health and Nutrition Examination Survey 2011-18. Front Nutr 2021; 8:687643.
26. Louzada MLC, Martins APB, Canella DS, Baraldi LG, Levy RB, Claro RM, Moubarac, JC, Cannon G, Monteiro CA. Ultra-processed foods and the nutritional dietary profile in Brazil. Rev Saude Publica 2015; 49:38.
27. Ferreira VA, Magalhães R. Obesidade entre os pobres no Brasil: a vulnerabilidade feminina. Cien Saude Colet 2011; 16(4):2279-2287, 2011.
28. Locher JL, Sharkey JR. An Ecological Perspective on Older Adult Eating Behavior. In: Bales C, Ritchie C. Nutrition and Health: Handbook of Clinical Nutrition and Aging. Totowa, NJ: Humana Press, 2009. p. 3–17.
29. Magnoni D, Stefanuto A, Kovacs C. Nutrição ambulatorial em cardiologia. São Paulo: Sarvier; 2007.
30. Yannakoulia M. Eating behavior among type 2 diabetic patients: a poorly recognized aspect in a poorly controlled disease. Rev Diabet Stud 2006; 3 (1): 11-6.
31. Fernandes DPS, Duarte MSL, Pessoa MC, Franceschini SCC, Ribeiro AQ. Evaluation of diet quality of the elderly and associated factors. Arch Gerontol Geriatr 2017; 72, 174-180.
32. Virtanen SM, Feskens EJ, Räsänen L, Fidanza F, Tuomilehto J, Giampaoli S, Nissinen A, Kromhout D. Comparison of diets of diabetic and nondiabetic elderly men in Finland, The Netherlands and Italy. Eur J Clin Nutr 2000; 54 (3): 181-6.
33. Silva GM, de Assumpção D, Barros MBA, Barros Filho AA, Corona, LP. Low dietary fiber intake in the elderly: a population -based study ISACAMP 2014/2015. Cien Saude Colet 2021; 26 (Suppl. 2): 3865-3874.
34. Loyal JPC. Anorexia of Aging. In: Leal JPC. Nutrition and Aging. [thesis]. Coimbra: School of Medicine, University of Coimbra, 2012.
35. Nilsen L, Hopstock LA, Skeie G, Grimsgaard S, Lundblad MW. The Educational Gradient in Intake of Energy and Macronutrients in the General Adult and Elderly Population: The Tromsø Study 2015–2016. Nutrients 2021; 13, 405.
36. Ferreira-Nunes PM, Papini SJ, Current JE. Dietary patterns and nutrient intake in the elderly: analysis with different methodological approaches. Cien Saude Colet 2018, 23 (12): 4085-4094.
37. Inzitar M, Doets E, Bartali B, Benetou V, Di Bari M, Visser M, Volpato S, Gambassi G, Topinkova E, De Groot L, Salva A. International Association Of Gerontology And Geriatrics (IAGG) Task Force For Nutrition In The Elderly. Nutrition in the age-related disablement process. J Nutr Heal Aging 2011; 15(8):599-604.
38. Buzzard M. 24-Hour Dietary recall and food record methods. In: Willet W, editor. Nutritional epidemiology. 2 ed. New York: Oxford University Press; 1998. p. 51-67.
39. Holanda LB, Barros Filho AA. Métodos aplicados em inquéritos alimentares. Rev Paul Pediatr 2006; v. 24, n. 1, p. 62-70.