Assessment of Fruit and Vegetable Intakes of Chronic Treated by Primary Healthcare

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1 Journal of Public Health in Developing Countries Vol. 2, No. 3, pp ISSN Original Contribution Open Access Assessment of Fruit and Vegetable Intakes of Chronic Treated by Primary Healthcare Disease Patients Estela Maria Barim 1, Maria Antonieta de Barros Leite Carvalhaes 2, Katia Cristina Portero McLellan 3,4, José Eduardo Corrente 5, Elen Rose Lodeiro Castanheira 6 1 Primary Health Care Clinic [Centro de Saúde Escola], Botucatu Medical School UNESP, Brazil 2 Department of Nursing, Botucatu Medical School UNESP, Brazil 3 Human Sciences, Food, Nutrition and Dietetics, Stephen F Austin State University, Nacogdoches, Texas, USA 4 Texas Institute for Kidney and Endocrine Disorders, Lufkin, Texas, USA 5 Biosciences Institute, Botucatu Medical School UNESP, Brazil 6 Department of Public Health, Botucatu Medical School UNESP, Brazil Correspondence to: Estela M. Barim, Primary Health Care Clinic [Centro de Saúde Escola], Botucatu Medical School UNESP, Rua Gaspar Ricardo, 181 Botucatu, Brazil. estela.barim@fmb.unesp.br ARTICLE INFO Article history: Received: 30 Jul 2016 Accepted: 21 Sep 2016 Published: 3 Nov 2016 Keywords: Chronic diseases Food intake Fruits Vegetables Primary healthcare Brazil ABSTRACT Background: Researchers and health institutions are increasingly concerned with monitoring fruit and vegetable (F&V) intakes of the Brazilian population. However, in the Brazilian primary healthcare system, nutrition education actions that focus on promoting F&V intakes are still incipient, so their potential to increase produce intake is still unknown. This cross-sectional case study aimed to assess the F&V intakes of adults treated at a primary healthcare clinic in São Paulo that develops many nutrition education actions. Methods: The non-random sample consisted of 181 adults. The participants answered a 24-hour dietary recall and a form with their socioeconomic, demographic, nutritional and health data, and participation in nutrition education actions at the healthcare clinic. Results: All participants had chronic diseases, and hypertension in women prevailed. Their mean daily F&V intake was grams, representing a mean of 8.7% of their total energy intake. Fewer than half the sample (40.9%) achieved the World Health Organization recommendation which stipulates that F&V should provide 9% of the total dietary energy intake. Women (p=0.0281), individuals aged more than 60 years (p=0.0172), and individuals who received nutritional care (p=0.0318) consumed more F&V. Conclusions: The association between nutritional care and higher F&V intakes supports the expansion of nutrition education actions in primary healthcare. Citation: Barim EM, Carvalhaes MABL, McLellan KCP, Corrente JE, Castanheira ERL. Assessment of Fruit and Vegetable Intakes of Chronic Disease Patients Treated by Primary Healthcare. J Public Health Dev Ctries. 2016; 2(3): The Authors All rights reserved, JPHDC. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 248

2 INTRODUCTION Inappropriate diets and inadequate fruit and vegetable (F&V) intakes are related to higher prevalences of chronic noncommunicable diseases (NCDs), such as diabetes, obesity, cardiovascular disease, and some types of cancer [1-4]. Researchers [5-7] and health institutions [8-10] are increasingly concerned with monitoring the F&V intakes of the Brazilian population. However, in the Brazilian primary healthcare system, nutrition education actions that focus on promoting F&V intakes are still incipient, so their potential to increase produce intake is still unknown. According to the World Health Organization (WHO), individuals should consume at least 400 grams of fresh F&V a day, or the equivalent of five F&V servings, which represent 9% (183 calories) of the calories in a 2000-calorie diet. According to the 2003 Family Budget Survey (POF), F&V contributed to 3.37% of a mean energy intake of 1800 calories, indicating that Brazilians produce intake is far below the recommendation [11]. The Brazilian situation is even worse when compared with the World Cancer Research Fund (WCRF) recommendation: a daily intake of non-starchy vegetables and fruits of 600g as a public health goal [12]. Jaime and Monteiro (2005) [5] conducted the first study that assessed individual F&V intakes in Brazil. They found that less than half (41%) of the interviewees consumed vegetables daily, less than one-third (30%) consumed fruits daily, only one in five individuals reported eating F&V daily, and only one in eight individuals consumed five or more F&V servings a day. At a median intake of 223 grams a day, the F&V intakes of the global population is below the recommendation, which varies considerably by region, gender, age, and education level [13,14]. Most abovementioned Brazilian studies on F&V intakes are based on population surveys on food acquisition. Although such studies provide elements for the development of actions that promote new food patterns, they lack further details on individual daily intake patterns. Many NCD patients who receive nutritional counseling concentrate in primary healthcare services, so it is important for these services to better know this pattern and to measure their ability to intervene and change the patients food habits. Thus, the present study aimed to investigate the F&V intakes of adults with chronic NCDs treated at primary healthcare clinics that develop nutrition education actions. MATERIALS AND METHODS Study Design and Setting This cross-sectional case study assessed the F&V intakes of a non-random sample of adult users of a public primary healthcare service located in a municipality in the mid-west region of the state of São Paulo, which has about 120,000 inhabitants. The selected healthcare unit is a primary healthcare unit that provides care, teaching, and research opportunities on mental health and health of adults, women, and children. It serves a population of roughly 30,000 inhabitants. Its users are mainly adults and older adults with chronic NCDs, such as overweight, obesity, diabetes, and high blood pressure, which is the demand profile of most primary healthcare clinics in Brazil [15-17]. Nutritional care actions are provided by all areas of care of the clinic, albeit with different approaches: individual nutritional care, educational group activity, and educational activity in the waiting room. Study Sample The sample consisted of users with different conditions who visited the adult division of the clinic in a period of 40 weekdays, from March to April Eight to twelve users were interviewed daily, totalling 200 interviewees. During this period, the adult division of the clinic was providing care for roughly 74 users a day. Of the 200 interviewees, 19 were excluded from the analyses for the following reasons: 16 had incomplete medical records, one had body mass index (BMI) 64.0 Kg/m 2, and the energy intakes of two individuals exceeded the acceptable limits (between 500 and 5000 calories, according to Nielsen and Adair [23]), so the final sample consisted of 181 individuals. 249

3 Demographic, Dietary & Anthropometric Assessments A trained dietitian used a 24-hour recall (24hR) to determine the F&V intakes of the interviewees. The software Programa de Apoio à Nutrição NutWin calculated the amounts of F&V in grams and their respective energy contents. Foods and preparations not listed in the program were obtained from food composition tables [18-21]. A registered dietitian collected socioeconomic, demographic, nutritional, and morbidity data from the users medical records right after the 24hR interview. The data were recorded in forms created for the present study, filled out by hand, and later digitized into a spreadsheet. Weight and height were measured by trained nurses on the day the 24hR was administered since the users had a medical appointment on that day. The information was recorded in the users medical records. Weight was measured in kg by a digital scale of the brand Filizola with a capacity of 150 kg and accuracy of 0.1 kg. Height was measured by a stadiometer mounted on the Filizola scale. The users were weighed wearing their usual clothes but barefoot. The participants nutritional status was classified according to BMI, as recommended by the Brazilian Food and Nutrition Surveillance System [Sistema de Vigilância Alimentar e Nutricional - SISVAN] [22]. Theoretical Model To investigate the factors associated with the users F&V intakes, a theoretical model with five domains was developed, based on the literature [2,24,25]. The domains were: socioeconomic, based on education level; demographic, based on gender, age in years, and age group (<40, 40-60, and >60 years); nutritional, based on BMI; health, based on the presence of NCDs; and use of health services, based on exposure to nutritional counseling in the last year. The inclusion criteria consisted of attending at least three individual nutritional care (INC) visits and at least three group education activity (GEA) meetings. Study Variables and Data Compilation The study outcome variables were daily F&V intakes in grams and in percentage of the total energy intake. The independent variables were education level, age, gender, body mass index (BMI in kg/m²), presence of morbidity (yes, no), and exposure to nutritional care (yes, no). A database was constructed with the consumed foods, quantities, and nutrients by exporting the NutWin data to Microsoft Excel A second database was constructed based on this first database using Statistical Analysis System (SAS) with the variables: consumed foods, consumed foods in grams, and energy provided by each food. Once the F&V were identified, the following variables were created: F&V intake in grams, F&V intake in calories, and percentage of daily energy intake provided by F&V. The participants F&V intakes were then classified as adequate (yes) or inadequate (no) according to the WHO and WCRF F&V intake recommendations [11,12]. Ethical Considerations The study was approved by the Research Ethics Committee of the School of Medicine of Botucatu, under protocol number CEP. The users were asked to sign an informed consent form the first time they were contacted. At the time, they were informed that the study would not pose any risks, discomfort, or inconveniences. The interviewees received a copy of the informed consent form. Statistical Analyses The quantitative variables were descriptively analyzed according to measures of central tendency and dispersion (mean, median, standard deviation, maximum value, and minimum value). The qualitative variables were expressed as absolute frequency and percentage. The Wilcoxon or Median test for variables with two categories and the Kruskal- Wallis test for variables with more than two categories compared the F&V intakes (in grams and percentage of total energy intake) by education level, age, gender, BMI, presence of morbidity, and exposure to nutritional care. The significance level was set at 5% (p<0.05). The Student s t-test investigated correlations of F&V 250

4 intakes with age and BMI. The data were analyzed by SAS for Windows, v RESULTS Demographic and Health Characteristics of the Participants The 181 participants had a mean age of 56.4 years (SD=16.3), a minimum age of 18 years, and a maximum age of 86 years; 69.1% were females, and 44.8% were aged more than 60 years, the prevalent age group. The most prevalent education level was 4 to 7 years of formal education (38.1%) followed by 0 to 3 years of formal education (30.4%). About one - third (34.3%) of the participants were of normal weight, 42.0% were overweight, and 23.8% were obese, that is, 65.8% of the participants had excess weight. Most participants (87.3%) had been diagnosed with one or more diseases. Roughly one-fifth (18.2%) of the sample participated in individual or group visits that included nutritional counseling (Table 1). Fruit and Vegetable Intakes The median F&V intake was grams, with a minimum value of 0.0 grams and a maximum value of grams, and the mean F&V intake was grams (SD=293.15). The median percentage of the total energy intake provided by produce was 7.5%, and the mean was 8.7%. The amount of energy provided by F&V varied greatly, from 0.0% to 41.1% as shown in Table 2. About 70% of the study individuals consumed less than 400g of F&V a day, and 88.4% consumed less than 600g. Moreover, 107 (59.1%) participants did not meet the recommended F&V intake of 9% of the total energy intake, 16 (8.8%) did not consume F&V, and 37 (20.4%) consumed less than 1.0% of the total energy intake in F&V. Of the 49 F&V consumed by the sample, the most popular were lettuce (consumed by 74 individuals, 40.9%), orange/mandarin (n=58, 32.0%), banana (n=52, 28.7%), tomato (n=50, 27.6%), papaya (n=22, 12.2%), carrot (n=21, 11.6%), apple (n=19, 10.5%), cucumber (n=15, 8.3%), arugula (n=12, 6.6%), lime (n=10, 5.5%), cabbage (n=10, 5.5%), and zucchini (n=10, 5.5%). The median percent energy intake from F&V differed significantly by gender, being higher in women (p=0.0281), and by age group, being higher in those aged 60 years or more (p=0.0172). Individuals exposed to nutritional care also had higher F&V intakes in grams (p=0.0318) and in percent of total energy intake than those who were not exposed to nutritional care (Table 3). The percent energy intake from F&V correlated with age, indicating that the relative F&V intake increased with age (Table 4). Table 1. Socio-demographic, Nutritional, and Health Characteristics of Participants (n=181) Characteristics Frequency % Age groups (years) < > Education level (years) Gender Female Male Body mass index Normal weight Overweight Obese Noncommunicable diseases Yes No Nutritional care Yes No

5 Table 2. Daily Fruit and Vegetable (F&V) Intakes of Study Participants (n=181) Median Mean SD Minimum Maximum P25 P75 F&V (grams) Energy from F&V (calories) % Dietary Energy Total Dietary Energy (calories) SD = Standard deviation; P25 = 25 th Percentile; P75 = 75 th Percentile Table 3. Socio-demographic, Nutritional, and Health Characteristics of Participants and their Fruit and Vegetable (F&V) Intakes (n=181) Characteristics F&V Intake (Grams) F&V Intake as % of Daily Energy Intake Median P-Value Median P-Value Age groups (years) < > Education level (years) Gender Female Male Body mass index Normal weight Overweight Obese Noncommunicable diseases Yes No Nutritional care Yes No

6 Table 4. Association of Fruit and Vegetable (F&V) Intake with Age and Body Mass Index Age BMI r p-value r p-value Age BMI F&V Intake (Grams) F&V % r=correlation coefficient; BMI=body mass index; F&V grams=intake of fruits and vegetables in grams; F&V %=F&V intake as a percentage of the daily energy intake DISCUSSION The users of the study healthcare clinic had very unsatisfactory F&V intake. Most participants (70%) did not reach the minimum recommended intake of 400 grams/day [11], and almost 90% did not consume 600 grams/day of F&V [12]. Additionally, the F&V intakes of one-fifth of the sample represented less than 1.0% of their total energy intake, and 8.8% did not consume any produce. However, these results are positively different from those of Brazilian and foreign population studies. According to the POF (2003) [11], F&V represented only 3% to 4% of Brazilians daily energy intake, as opposed to 8% in the study sample. More recent POF ( ) data [26] have shown that 90% of Brazilians consume less than 400 grams/day of F&V, against 70% in the study sample. The particular sample profile (many older adults, and high proportions of women and individuals with chronic diseases) may explain their higher F&V intakes compared with the general population. A household survey about risk behaviors and self-reported diseases conducted in 15 Brazilian state capitals and the Federal District found that women consumed F&V more frequently and younger individuals had lower intakes [8]. In a cross-sectional, populationbased study from the city of São Paulo, Figueiredo et al [25] also found that women and older adults had higher F&V intake frequencies. In another Brazilian study, Jaime and Monteiro [5] found that F&V intake frequency tended to be higher in women, but women and men had inadequate produce intake. In addition, F&V intakes tended to increase with age and education level. Similar results to those mentioned above were found in other Brazilian municipalities, such as Ribeirão Preto, SP [27], and Pelotas, RS [7]. Foreign studies have confirmed higher F&V intakes by women, older adults, and individuals with higher socioeconomic level [28,29]. In the present study, individuals with NCDs presented higher F&V intakes in grams and percentage of daily energy intake than those without NCDs, but the difference was not statistically significant. Many studies have indicated that illness promotes the adoption of healthy behaviors. In a systematic review about the impact of interventions and programs that encourage F&V intake, Pomerleau et al [4] found that they were more effective in individuals with preexisting conditions. The most interesting finding with respect to its usefulness to primary healthcare services was that users who participated in individual or group nutritional counseling had higher F&V intakes, suggesting a positive response to these activities, even though this finding cannot be considered in isolation because of the determinants mentioned previously. In a study on eating behavior, Toral & Slater [30] stated that one of the determinants of health-related behaviors is the perception that a recommended action may reduce health risk. In 253

7 other words, they pointed out the essentialness of recognizing the need and possibility of changing food habits to begin doing so which was has been successfully provided to users the opportunity to come to this realization. Our findings suggest that individuals with chronic diseases treated at a primary healthcare clinic are sensitized to care for their health, and when exposed to nutritional approach actions, they are more likely to change their diet. On the other hand, the results also indicate the need of expanding the approaches that promote F&V intakes to target younger users, males, users with lower education level, and users who are not participating in nutritional monitoring activities. The present study is unique because it assessed the individual F&V intakes of a specific population segment: users of public healthcare services. Nonetheless, by focusing on the users of a single unit, specificity and knowledge about this population group increase and the ability to generalize the results decreases, even when the results agree with those of population-based studies. The use of a single 24-hour recall per individual to assess dietary intake may be considered the biggest limitation of this study. Yet, assessing a single day to estimate the mean intake of specific population groups is considered acceptable by some authors [31]. Further studies are needed to confirm the positive effects of nutritional counseling actions provided by primary healthcare. New studies should use more dietary surveys and include a control group. CONCLUSIONS Primary healthcare users consume more fruits and vegetables than the general population, suggesting a phenomenon of reverse causality since most users already have some chronic disease and are encouraged by the positive effects of the care they receive. The finding that users exposed to specific nutrition education actions (groups, waiting rooms, and individual visits) consume even more F&V turns the positive impact of such actions into a probable hypothesis. When discussing the role of nutritional care provided by primary healthcare, results from an original case-control study support the hypothesis that primary healthcare actions may be effective. AUTHORS CONTRIBUTIONS EMB coordinated data collection and nutritional calculations, helped to conceive and design the study, analyzed and interpreted the data, and wrote the article. MABLC, KCPM, JEC, ERLC helped to analyze and interpret the data and reviewed the article. All authors have read and approved the final manuscript. CONFLICT OF INTEREST Authors have declared that no competing interests exist. REFERENCES 1. Garófolo A, Avesani CM, Camargo KG, Barros ME, Silva SRJ, Taddei JAAC, et al. Dieta e câncer: um enfoque epidemiológico. (Diet and Cancer: an epidemiological focus). Rev Nutr. (Brazilian Journal of Nutrition). 2004; 17: Barreto SM, Figueiredo RC. Doença crônica, auto-avaliação de saúde e comportamento de risco: diferença de gênero. (Chronic disease, health self-assessment, and risk behavior: difference between genders). Rev Saúde Pública. (Brazilian Journal of Public Health). 2009; 43: Viebig RF, Valero MP. Desenvolvimento de um questionário de freqüência alimentar para o estudo de dieta e doenças não transmissíveis. (Development of a food frequency questionnaire to study diet and noncommunicable diseases) Rev Saúde Pública. (Brazilian Journal of Public Health) 2004; 38: Pomerleau J, Lock K, Knai C, Mckee M. Interventions designed to increase adult fruit and vegetables intake can be effective: a systematic review of the literature. J Nutr. 2005; 135: Jaime PC, Monteiro CA. Fruit and vegetable intake by Brazilian adults, Cad Saúde Pública. 2005; 21: Moura EC, Neto OLM, Malta DC, Moura L, Silva NN, Bernal R, et al. Vigilância de fatores 254

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