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Tools developed in Brazil for the promotion and assessment of adequate and healthy eating habits: A scoping review

Alinne Paula de Almeida¹, Priscila Vaz de Melo Ribeiro², Daniela Mayumi Usuda Prado Rocha³, Luiza Carla Vidigal Castro 4 and Helen Hermana Miranda Hermsdorff 5

1. Ph.D. in Nutrition. Research Scientist. Department of Nutrition and Health, Federal University of Viçosa, Viçosa, Minas Gerais, Brazil. Email:alinne.almeida@yahoo.com.br. ORCID: 0000-0003-4158-8595
2. Ph.D. in Nutrition. Research Scientist. Department of Nutrition and Health, Federal University of Viçosa, Viçosa, Minas Gerais, Brazil. Email: priscilavazdemelo@yahoo.com.br. ORCID: 0000-0002-6996-1796
3. Ph.D. in Nutrition. Research Scientist. Department of Nutrition and Health, Federal University of Viçosa, Viçosa, Minas Gerais, Brazil. Email:daniela.rocha@ufv.br. ORCID: 0000-0001-6130-0179
4. Ph.D. in Nutrition. Teacher. Department of Nutrition and Health, Federal University of Viçosa, Viçosa, Minas Gerais, Brazil. Email:luiza.castro@ufv.br. ORCID: 0000-0002-7613-1416
5. Ph.D. in Nutrition. Teacher. Department of Nutrition and Health, Federal University of Viçosa, Viçosa, Minas Gerais, Brazil. Email:helenhermana@ufv.br. ORCID: 0000-0002-4441-6572
Corresponding Author: Helen Hermana Miranda Hermsdorff. Avenue Ph Rolfs s/n, University Campus. DNS/UFV. Viçosa – MG 36570-900 Brazil. Telephone: +55 31 3899-1269, Fax: +55 31 3899-2541. Email:helenhermana@ufv.br

Abstract
The objective of this study was to identify and discuss the tools for the promotion and evaluation of adequate and healthy eating based on the Food Guide for the Brazilian Population. The scoping review was conducted according to the JBI Manual for Evidence Synthesis via the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and by searching PubMed/MEDLINE, EMBASE, Scielo and Lilacs. Sixteen studies on relevant tools, based on the food guide for individuals of all age groups, were thus included: two descriptive studies, two randomized clinical trial protocols, eleven methodological analyses, and one psychometric paper, aimed at either a focal population (n = 12) or health professionals (n=4). Six studies addressed tools for promoting adequate and healthy eating, and ten developed tools for evaluating dietary practices or the knowledge and activities of health professionals. This review can therefore assist health professionals in choosing instruments for the implementation and/or dissemination of food guide recommendations, contributing to the promotion of adequate and healthy eating habits.
Keywords: Food Guides, Nutrition Policy, Food and Nutrition Education, Food and Nutrition Health Promotion.

Introduction
Adequate and healthy food is a basic human right1 that involves the guarantee of permanent and regular access to an adequate dietary practice and must be in accordance with special dietary needs and the relevant culture, accessible, harmonious in quantity and quality, and based on sustainable production practices. The guideline for the Promotion of Adequate and Healthy Food (PAHF) is part of the National Food and Nutrition Policy and involves strategies such as food and nutrition education (FNE) and encouragement to create environments that promote adequate and healthy food to provide individuals and communities with appropriate dietary practices. This guideline is one of the priorities of the National Policy for Health Promotion, and for its implementation, the development of intersectoral actions in different spheres of government, together with society, must be articulated2.
PAHF actions should support individuals in adopting healthy lifestyles, as well as identify and critically analyze unhealthy habits and practices. The set of these strategies contributes to the expansion of health actions, stimulating innovative alternatives that foster the development of individuals2. In this context, the Food Guide for the Brazilian Population (FGBP) constitutes one of the strategies for implementing PAHF guidelines3.
The FGBP is an instrument for supporting and encouraging healthy eating practices and subsidizing the policies, programs, and actions for promoting the health and food and nutrition security (FNS) of the population. It is based on a broader concept of adequate and healthy eating, taking into account biological, sociocultural, and environmental aspects at the individual and collective levels. Its recommendations cover practices related to food choice, eating and commensality, in addition to highlighting possible obstacles to healthy eating practices, such as information, supply, cost, culinary skills, time or advertising3,4. These recommendations are presented qualitatively, guided by the golden rule “always prefer natural or minimally processed foods and culinary preparations to ultra-processed foods” 3.
In fact, food-based dietary guidelines with qualitative recommendations facilitate the dissemination and understanding of information on adequate and healthy eating because they are simple, realistic and flexible4,5. However, during the implementation of these recommendations, challenges may occur, due to, e.g., the use of language and visual resources that are not very understandable by the population or the absence of educational materials, an effective validation of the recommendations, or a multidisciplinary team qualified to disseminate these recommendations6,7. Such challenges hinder the adoption of adequate and healthy eating practices by the population8. Thus, the creation of tools that support and disseminate the recommendations in these dietary guidelines is essential for the adoption of these dietary practices in the daily life of the population8.
Therefore, to track and gather all the requisite tools for the evaluation and promotion of adequate and healthy eating produced by the FGBP, this scoping review was conducted to identify and discuss the salient literature regarding these tools.
Methods
Protocol and registration
This scoping review was conducted according to the JBI Manual for Evidence Synthesis9 via the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) 10 checklist10 and registered with the OSF (Registration DOI 10.17605/OSF. IO/TC7GD: https://archive.org/details/osf-registrations-tc7gd-v1). This analysis was guided by a main question: “What are the tools, based on the Food Guide for the Brazilian Population published in 2014, for the promotion and evaluation of adequate and healthy eating habits?”
Eligibility criteria
Articles that have developed tools for the promotion and evaluation of adequate and healthy eating among individuals of all age groups, based on the FGBP, were included in thus review. Studies from any geographic setting were eligible for inclusion. Nonoriginal studies (comments, reviews, letters to the editor, case reports, theses, and abstracts) were excluded. Studies published before 2014 were also considered ineligible because the focal FGBP instrument was first published in 2014.
Search strategy
The search for original articles was performed using the following electronic bibliographic databases: PubMed/MEDLINE (www.pubmed.com), EMBASE (www.embase.com/landing?status=gray), Scielo (www.scielo.br) and Lilacs (www.lilacs.bvsalud.org).
The keywords were chosen from the Medical Subject Headings (MeSH) and Descriptors in Health Sciences (DeHS) using the search terms described in the Supplementary Material.
The search strategy was not restricted by language. The last search was performed on March 28, 2022. A reverse manual search was also performed to identify the relevant articles cited in all selected studies.
Selection of studies
The authors (APA and PVMR) independently performed the study selection in three phases: analysis of titles, reading of abstracts, and reading and comprehension of full texts.
Any divergent decisions were resolved by consensus or, if necessary, by a third author (DMUPR). Duplicate articles in different databases were identified and excluded using Mendley®, and the peer review process was performed via Rayyan QCRY® Software, which ensured independent (blind) evaluation by the authors.
Data extraction
Two reviewers (APA and PVMR) extracted relevant information from the eligible studies, following an extraction table prepared by the researchers: (i) name of the first author, year of publication; (ii) study design; (iii) tool; (iv) target audience; (v) tool components; and (vi) evaluation of the psychometric properties (whether the study performed an evaluation of the psychometric properties validity and reliability and regarding the methods adopted for the evaluation) of the relevant tool. This information was extracted as presented in these studies; however, those that did not clearly explain any of the above parameters according to the information presented were classified by the authors as such. Any disagreements were resolved by a third author (DMUPR).
Data analysis
The data extracted from the selected studies are summarized in Tables 1 and 2 and separated by tools, based on the FGBP, for the promotion and evaluation of adequate and healthy eating. These studies are organized chronologically by year of publication, starting from the first published study.
Results
Selected studies
A total of 1,207 studies were identified after searching the PubMed, EMBASE, Scielo and Lilacs databases. Notably, no articles were found in the reverse manual search. A total of 293 duplicate studies were removed, resulting in 914 unique records. After a complete reading of the abstracts, 46 studies were identified. Finally, after reading the full texts, 16 studies were selected because they met all the criteria adopted for this scoping review. The reasons for excluding the other studies are indicated in Figure 1.
Description of included studies
The main characteristics of the sixteen studies included in this review are described in Tables 1 and 2. Regarding study design, two were descriptive12,13, two adopted the protocol of a randomized clinical trial14,15, eleven were methodological6,16–25, and one was psychometric26.
Six studies12–16,18 addressed tools for promoting adequate and healthy eating, and ten 6,17,19–26 reported on tools for assessing diets or eating practices.
Among the six tools for promoting adequate and healthy eating, an iconographic instrument12 can facilitate the understanding of the NOVA classification (categorizes foods into four distinct groups according to the extent and purpose of processing)27 to provide the population greater autonomy in food selection: a digital card game, Rango Cards14, for promoting healthy eating among adolescents; an educational workshop13 for training health professionals to effectively promote educational activities for implementing FGBP recommendations; two messaging tools for promoting healthy eating in the population, one containing messages16 supporting the adoption of healthy eating choices and behaviors and one15 messages, via WhatsApp, for promoting adequate and healthy eating; and a clinical protocol18 guiding Primary Health Care (PHC) professionals offering individual dietary advice.
The ten studies on feeding assessment tools included a Diet Quality Index adapted to pregnant women19; two6.26 scales for assessing dietary practices; a data collection instrument20 for auditing consumer food environment; an index21 that assesses the degree of confidence in cooking skills22; a scale for evaluating FNE practices; a scoring system23 for assessing the healthiness of consumer food environment; an online instrument for assessing24 the knowledge of health professionals about the FGBP; an online scale25 for measuring the effectiveness of professionals in applying FGBP recommendations; and a questionnaire17 on the knowledge of and feeding practices for children.
Two tools for promoting adequate and healthy eating are intended for use by health professionals among the general population12,18: two others14,15 are for use among teenagers, one16 for adults, and one13 for the continuing education of health professionals. Among the tools for assessing diet, three17,19,22 are intended exclusively for professional nutritionists; two17,19 for nutritionists to evaluate the population’s dietary practices; one22 for nutritionists to evaluate other professionals working in PHC; seven for health professionals in general and five6,20,21,23,26 for particular evaluation of the population’s eating practices or food environment; and two24,25 for the evaluation of the knowledge of PHC professionals about FGBP recommendations and their application in professional practice.
Finally, fifteen studies evaluated the psychometric properties of the developed tools (Table 3). Eleven studies 6,13,15–18,20,22,24–26 validated content; all conducted focus groups, four13,17,20 calculated the content validity index (CVI), two18,26 performed content analysis, and three22,24,25 calculated mean representativeness and clarity scores in addition to completing focus groups. Seven studies6,17,18,21,22,24,25 validated their focal tool(s); one18 conducted focus groups and content analysis, one6 conducted a pretest with its focal audience, and five17,21,22,24,25 showed a consensus only among a group of experts and/or the target audience of the tool(s). Five studies6,22–25 validated their constructs; four6,17,24,25 performed factor analysis and one23 performed Kruskal‒Wallis and Dunn tests. Reliability was also assessed in different ways. Four studies17,19,20,22 assessed it through the degree of agreement, four6,17,20,21 assessed reproducibility, four 6,17,21,23assessed internal consistency, and one26 assessed reliability through item dimensionality and item response theory. Finally, one study14 evaluated viability, usability and attractiveness through a convenience sample of teenage gamers (all were interested in the topic, and the age group (14 to 16 years) was compatible with the target audience of the game).
Discussion
To the best of our knowledge, this is the first scoping review to identify, discuss and summarize the tools available for the promotion and evaluation of adequate and healthy eating habits based on the FGBP (2014)(Table 4).
The importance of the Food-Based Dietary Guidelines for the adoption of healthy eating practices
Food-based dietary guidelines are tools for promoting healthy eating habits and lifestyles among the population of a country4,28,29. According to the Food and Agriculture Organization of the United Nations (FAO), its Food Guidelines are intended to serve as a basis for the formulation of national policies on food and nutrition, health and agriculture, as well as for food and nutrition education programs for promoting healthy eating habits and lifestyles. They provide the general public with guidance on the foods, food groups and dietary patterns that provide essential nutrients for promoting general health and prevent chronic noncommunicable diseases (NCDs)30.
Dietary guidelines should be determined by public health issues and the sociocultural context (relevant social, economic, agricultural and environmental factors that affect food availability and dietary patterns) of each country; they should reflect dietary patterns rather than numerical targets, i.e., should be positive and encourage the pleasure of an adequate and healthy diet and based on evidence8.
In this context, in Brazil, the second version of the FGBP, published in 20143, plays a strategic role in encouraging public policies on food and nutrition and in guaranteeing the human right to adequate food and food sovereignty. With a qualitative approach guided by the degree of food processing and the sustainability of food systems, it consciously aims to ensure the health and nutrition of the Brazilian population and overcomes the idea of being a mere instrument for FNE actions4,5,28.
The fact that there are dietary guidelines does not, however, guarantee an effective nutritional policy or that the population will follow these guidelines. In addition to these guidelines having a solid scientific basis, they must present a set of factors for the effective communication of information to the public. These guidelines should be practical, understandable, culturally accepted, multimedia, multisectoral, address all groups and ages, and complement existing community programs8,31.
Therefore, when the foods or food groups recommended in such guidelines are not accessible, widely available, and based on the food culture of the focal country, these dietary guidelines’ language and visual resources are not understandable; their design and implementation does not involve various sectors (nongovernmental organizations, the public sector or private companies) and professionals (educators, health professionals, social workers, extension workers, communication specialists, among others) in society; the professionals key to their dissemination lack the necessary education/training in and knowledge of their importance; there is no pilot testing or validation of the guidelines with nutritionists and their target audience; their recommendations are not effectively transformed into educational materials or disseminated across various media; and the time devoted to FNE activities is inefficient: All of these issues are obstacles that hinder an adequate implementation of the recommendations and dietary guidelines8.
In addition, the production and distribution of educational materials in various media (folders, booklets, videos, among others) and the training of professionals who disseminate the relevant recommendations are fundamental in the successful implementation of dietary guidelines and, consequently, the adoption of adequate and healthy eating habits by the population32. Thus, the tools discussed in this article facilitate overcoming such obstacles and act as facilitators in the implementation of FGBP recommendations, rendering these messages more accessible to the Brazilian population while encouraging the adoption of an adequate and healthy diet.
Tools for the promotion of adequate and healthy eating based on the Food Guide for the Brazilian Population
In this review, three studies14–16 developed tools based on mHealth to disseminate FGBP recommendations among the population. Khandpur et al.16 developed 28 messages based on FGBP recommendations, sent through a digital platform. Melo et al.15 used smartphones and WhatsApp messages for promoting healthy eating, and Chagas et al.14 developed a digital game (use on smartphones and tablets) to present this concept to the adolescent public. Therefore, the use of mHealth can be an important strategy for promoting adequate and healthy eating practices during the nutritional counseling process in different age groups. Mobile health is a medical and public health practice supported by the use of cell phones, user monitoring devices, personal digital assistants and other wireless devices, which improve communication between health professionals and users and promote healthy lifestyles. Mobile health applications present a good opportunity for behavioral change interventions that require sustained adherence by keeping users engaged during health monitoring33–35.
The FGBP focuses on concepts and information that need to be transmitted to the population in an objective, didactic way that promotes knowledge retention. In this sense, the tool developed by Geraldi et al.12 can be used as supporting material in individual and group nutritional consultations on FNE, mediating and facilitating guidance on NOVA classifications through iconographic visual resources that support individuals in making adequate and healthy food choices with more autonomy. Among the strategies in the health area aimed at PAHF, the FNE is included. The development of personal skills in food and nutrition implies thinking of FNS as a process of dialog between health professionals and the population, which is of fundamental importance in the exercise of autonomy, self-care and empowerment regarding the adoption of adequate and healthy eating practices2,36. The FNS represents a set of actions (problematic and active approaches and educational resources) that are essential in facilitating the voluntary adoption of healthy eating practices that lead to health promotion36,37.
In addition, Jaime et al.13 developed a protocol for a continuing education workshop for PHC professionals that promotes the implementation of GAPB recommendations among the population and, consequently, the adoption of adequate and healthy eating practices. Louzada et al.18 developed a protocol for PHC professionals to apply the FGBP in individual dietary counseling. The creation of clinical guidelines may be an action for adapting professional practice and improving the quality and efficiency of care offered to users38. Thus, the important role of health professionals in the successful implementation of the recommendations of the dietary guidelines among the population is highlighted. These professionals should be encouraged to acquire the basic information necessary to interpret the recommendations provided by dietary guidelines. For this, the education, qualification and training of these professionals can be planned to sensitize and educate them to fully understand the concepts and specific messages presented in the guidelines, whereby the actual implementation of the recommendations among the population occurs8. Health education consists of the production and systematization of knowledge related to training and development in health care, involving teaching practices, didactic guidelines, and curricular guidance. One of the modalities of health education is continuing health education, which consists of the learning process occurring in professionals\' workspace, where learning and teaching are incorporated into daily life at organizations and during work39.
Assessment tools for adequate and healthy eating based on the FGBP
The evaluation process is essential in verifying adherence to adequate and healthy eating practices, the extent to which the food environment promotes adequate and healthy eating, the acceptability and credibility of the salient recommendations, and what knowledge the population and health professionals should have acquired after the implementation of dietary guidelines and SAP tools. The results of an evaluation process can be used to modify or adjust these guidelines and tools, improving the impact and adherence of these recommendations among the population8,40. Given this context, tools such as the Diet Quality Index Adapted for Pregnant Women19, a questionnaire for assessing knowledge of healthy eating habits and practices among children17, the Culinary Skills Index21, the Diet Quality Scale (SQUARE)26, and the scale for measuring healthy eating practices6 are relevant for implementing and disseminating GAPB recommendations for adequate and healthy eating practices based on prior knowledge about the eating practices in a specific population.
In turn, the FGBP recognizes the role of the food environment in PAHF3, defined as both the collective physical, economic, political and sociocultural space and the opportunities and conditions therein that influence the availability, access, selection, preparation and consumption of food and beverages, eating habits, the formation of eating habits, and nutritional status41–43. In this sense, the instrument for auditing the food environment (AUDITNOVA)20 and its scoring system23 make it possible to capture information such as availability, price, promotional and advertising strategy, number of brands available, and the healthiness of the consumer food environment by using, as a theoretical basis, the recommendations (NOVA classification) of the FGBP. In fact, this evaluation process is of fundamental importance because it can demonstrate the relationship between the consumer food environment and the development of CNCDs, thus supporting the creation of public policies that regulate the availability and advertising of food in these spaces23.
According to the preparation and use of food-based dietary guidelines8, for the implementation of dietary guidelines to be successful, the professionals who act as the promoters of their recommendations need to have adequate knowledge of the information contained therein to optimally disseminate this information to the population. Thus, the evaluation of this knowledge among professionals24, of the ability of health professionals to promote dietary advice25, and of the FNE practices applied by these professionals22 in promoting FGBP recommendations are fundamental for obtaining knowledge of the gaps and points that need improvement in food and nutrition guidance. Accordingly, mechanisms can be created to train health professionals, enabling the propagation of FGBP recommendations more efficiently and, consequently, achieving more success in PAHF among the population.
Evaluation of the psychometric properties of the tools
For a tool to be used in research or professional practice, its psychometric properties, that is, its reliability and validity, must be evaluated and considered appropriate. Reliability, one of the main quality criteria of an instrument, is the ability to reproduce a consistent result across time, space and different observers, demonstrating the aspects of stability (degree to which similar results are obtained at two different times), internal consistency (indicates whether the domains of an instrument measure the same characteristic) and equivalence (degree of agreement between two or more observers regarding the scores of an instrument)44–46.
Validity, on the other hand, entails that an instrument measures exactly what it purports to measure, i.e., it is based on the degree to which the content thereof adequately reflects the construct being measured (content validity). The degree to which a group of variables represents the construct to be measured (construct validity) and the degree to which the instrument is related to some external criterion are widely accepted measures (criterion validity)44–46.
Of the sixteen studies included in this review, seven6,17,20–23,26 assessed the validity and reliability of their FGBP-based tools. Notably, these tools must be accurate, valid and interpretable to allow their application in the population. Thus, when these studies present, in their methodologies, quality evaluations, either by validity or reliability, these help professionals to reliably and validly determine the most appropriate tool to be applied in professional practice according to the circumstances, population, type and purpose of each PAHF action44–46.
Strengths and limitations
The articles included in this scoping review have observable strengths, such as their objective tools that are easily applied and used in professional routines to evaluate dietary practices, the consumer food environment, professional practices, and SAPS. However, these articles also have some limitations, such as a lack of standardization among the studies assessing psychometric properties and a divergence in the methodologies applied in the evaluation of reliability and validation. Moreover, not all the articles evaluated the reliability and validity of the focal tools. In addition, few studies developed nonvirtual tools or tools that do not depend on resources such as the internet, computers and cell phones for their application in professional practice. Finally, the development of more studies that address the creation of tools for the qualification of health professionals working in PHC is still necessary.
Conclusion
The present review has identified tools for the promotion and evaluation of adequate and healthy eating, their applicability, and the audience for which each of them is intended. These tools are essential for the implementation and dissemination of the recommendations proposed by the FGBP. This review can therefore assist health professionals in choosing the most appropriate instrument for the promotion and evaluation of healthy eating practices, thereby improving the actions for promoting healthy eating in health settings.

Acknowledgments
This review is related to the project “Elaboration of instructions and instruments for the management of obesity in the Unified Health System: From prevention to treatment”, supported by the Letter of Agreement between the Arthur Bernardes Foundation and the Pan American Health Organization (Funarbe/PAHO/UFV)., process SCON2021-00201). It was also supported by CNPq/MS/ SAPS/ DEPROS (442317/2020-4). HHM Hermsdorff is a CNPq Productivity fellow – 1D-level (308772/2017-2).

Funding
Letter of Agreement between the Arthur Bernardes Foundation and the Pan American Health Organization (Funarbe/PAHO/UFV, process SCON2021-00201), and CNPq/MS/ SAPS/ DEPROS (process 442317/2020-4).

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