Diet quality index for Brazilian adolescents: the ERICA study



This study aimed to assess the dietary patterns of adolescents using a food-based diet quality index and their compliance with a healthy dietary guideline


Participants included 71,553 Brazilian adolescents (12–17 years old) from the Study of Cardiovascular Risks in Adolescents (ERICA), a cross-sectional school-based multicenter study.. Dietary intake was measured by one 24-h recall. A second recall was collected in a random subsample (~ 10%) to correct within-person variability. The Diet Quality Index for Adolescents adapted for Brazilians (DQIA-BR) was used to measure the overall quality of the dietary intake. The National Cancer Institute method was applied to estimate usual dietary intake. The DQIA-BR and the distribution of its components (quality, diversity, and equilibrium) were analyzed according to sex, geographical area, and type of school


The mean (SD) DQIA-BR scores were 14.8% (6.1%) for females and 19.0% (6.3%) for males. All analyzed strata revealed low scores of DQIA-BR and its components. The median usual intake was five to sevenfold below the recommendations for vegetables and fruits and approximately twofold below the recommendations for dairy. The highest DQIA-BR mean scores were found in the northern region [17.0% (6.4%), females; 20.7% (6.3%), males]. Adolescents in both types of schools had relatively similar median intakes of snacks (~ 85 g) and sugared drinks (~ 600 ml)


The overall diet quality of Brazilian adolescents is inadequate based on evaluated parameters in all regions and socioeconomic backgrounds.

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  1. 1.

    World Health Organization (2011) Global status report on noncommunicable diseases 2010. World Health Organization, Geneva.;jsessionid=44A9657450CEB0457EAC84CE149CB243?sequence=1

    Google Scholar 

  2. 2.

    Swinburn BA, Sacks G, Hall KD et al (2011) The global obesity pandemic: shaped by global drivers and local environments. Lancet 378(9793):804–814

    PubMed  Google Scholar 

  3. 3.

    Cespedes EM, Hu FB (2015) Dietary patterns: from nutritional epidemiologic analysis to national guidelines. Am J Clin Nutr 101(5):899–900

    CAS  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Tucker K (2010) Dietary patterns, approaches, and multicultural perspective. Appl Physiol Nutr Metab 35(2):211

    PubMed  Google Scholar 

  5. 5.

    Sotos-Prieto M, Bhupathiraju SN, Mattei J et al (2017) Association of changes in diet quality with total and cause-specific mortality. N Engl J Med 377(2):143–153

    PubMed  PubMed Central  Google Scholar 

  6. 6.

    Waijers PM, Feskens EJ, Ocké MC (2007) A critical review of predefined diet quality scores. Br J Nutr 97(2):219–231.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Mikkilä V, Räsänen L, Raitakari OT et al (2005) Consistent dietary patterns identified from childhood to adulthood: the cardiovascular risk in Young Finns Study. Br J Nutr 93(6):923–931

    PubMed  Google Scholar 

  8. 8.

    World Health Organization (2016) Report of the commission on ending childhood obesity. Geneva

  9. 9.

    Gates M (2016) Advancing the adolescent health agenda. Lancet 387(10036):2358

    PubMed  Google Scholar 

  10. 10.

    Dick B, Ferguson BJ (2015) Health for the world’s adolescents: a second chance in the second decade. J Adolesc Health 56(1):3–6

    PubMed  Google Scholar 

  11. 11.

    World Health Organization (2005) Nutrition in Adolescence: issues for the health sector: issues in adolescent health and development. Geneva

  12. 12.

    Marshall S, Burrows T, Collins CE (2014) Systematic review of diet quality indices and their associations with health-related outcomes in children and adolescents. J Hum Nutr Diet 27(6):577–598.

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Lazarou C, Newby PK (2011) Use of dietary indexes among children in developed countries. Adv Nutr 2(4):295–303.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Collins C, Watson J, Burrows T (2010) Measuring dietary intake in children and adolescents in the context of overweight and obesity. Int J Obes 34(7):1103

    CAS  Google Scholar 

  15. 15.

    Conde WL, Monteiro CA (2014) Nutrition transition and double burden of undernutrition and excess of weight in Brazil. Am J Clin Nutr 100(6):1617S–1622S

    CAS  PubMed  Google Scholar 

  16. 16.

    Veiga GV, Araújo MC et al (2013) Inadequate nutrient intake in Brazilian adolescents. Revista de Saúde Pública 47:212 s–221 s

    Google Scholar 

  17. 17.

    Souza AeM, Barufaldi LA, Abreu GeA et al (2016) ERICA: intake of macro and micronutrients of Brazilian adolescents. Rev Saude Publica.

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Bloch KV, Szklo M, Kuschnir MC et al (2015) The Study of cardiovascular risk in adolescents–ERICA: rationale, design and sample characteristics of a national survey examining cardiovascular risk factor profile in Brazilian adolescents. BMC Public Health 15:94.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Habicht J (1974) Standardization of quantitative epidemiological methods in the field. Boletin de La Oficina Sanitaria Panamericana Pan American Sanitary Bureau 76(5):375

    CAS  PubMed  Google Scholar 

  20. 20.

    Vasconcellos MT, Silva PL, Szklo M et al (2015) Sampling design for the study of cardiovascular risks in adolescents (ERICA). Cad Saude Publica 31(5):921–930.

    Article  PubMed  Google Scholar 

  21. 21.

    Lohman T, Roche A, Martorell R (1991) Anthropometric standardization reference manual. Human Kinetics Books, Champaign, Illinois

    Google Scholar 

  22. 22.

    Onis M, Onyango AW, Borghi E et al (2007) Development of a WHO growth reference for school-aged children and adolescents. Bull World Health Organ 85(9):660–667

    PubMed  PubMed Central  Google Scholar 

  23. 23.

    Barufaldi LA, Abreu GdA, Veiga, GVd et al (2016) Software to record 24-hour food recall: application in the study of cardiovascular risks in adolescents. Revista Brasileira de Epidemiologia 19(2):464–468

    PubMed  Google Scholar 

  24. 24.

    Conway JM, Ingwersen LA, Vinyard BT et al (2003) Effectiveness of the US Department of Agriculture 5-step multiple-pass method in assessing food intake in obese and nonobese women. Am J Clin Nutr 77(5):1171–1178

    CAS  PubMed  Google Scholar 

  25. 25.

    Tooze JA, Midthune D, Dodd KW et al (2006) A new statistical method for estimating the usual intake of episodically consumed foods with application to their distribution. J Am Diet Assoc 106(10):1575–1587

    PubMed  PubMed Central  Google Scholar 

  26. 26.

    Freedman LS, Guenther PM, Dodd KW et al (2010) The population distribution of ratios of usual intakes of dietary components that are consumed every day can be estimated from repeated 24-hour recalls. J Nutr 140(1):111–116.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Souza AdM, Pereira RA, Yokoo EM et al (2013) Most consumed foods in Brazil: National Dietary Survey 2008–2009. Revista de Saúde Pública 47(Suppl. 1):190s–199s.

    Article  Google Scholar 

  28. 28.

    Instituto Brasileiro de Geografia e Estatística (2011) Pesquisa de Orçamentos Familiares (POF), 2008–2009: tabela de medidas referidas para os alimentos consumidos no Brasil. Instituto Brasileiro de Geografia e Estatística, Rio de Janeiro.

    Google Scholar 

  29. 29.

    Instituto Brasileiro de Geografia e Estatística (2011) Pesquisa de Orçamentos Familiares (POF), 2008–2009: tabela de medidas referidas para os alimentos consumidos no Brasil. Instituto Brasileiro de Geografia e Estatística, Rio de Janeiro.

    Google Scholar 

  30. 30.

    Silva TL, Klein CH, Souza AeM et al (2016) Response rate in the study of cardiovascular risks in adolescents—ERICA. Rev Saude Publica 50 Suppl 1.

  31. 31.

    Vyncke K, Cruz Fernandez E, Fajó-Pascual M et al (2013) Validation of the diet quality index for adolescents by comparison with biomarkers, nutrient and food intakes: the HELENA study. Br J Nutr 109(11):2067–2078.

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    Vlaams Instituut voor Gezondheidspromotie (VIG) (2006) De actieve voedingsdriehoek: een praktische voedings- en beweeggids (The active food pyramid: a practical guide to diet and physical activity). Vlaams Instituut voor Gezondheidspromotie, (VIG), Brussels.

    Google Scholar 

  33. 33.

    World Health Organization (2000) CINDI dietary guide. World Health Organization, Geneva.

    Google Scholar 

  34. 34.

    Joint FAO/WHO, Consultation (1996) Preparation and Use of Food-based Dietary Guidelines. WHO Technical Report Series 880. Report of a joint FAO/WHO consultation. Nicosia

  35. 35.

    Ministério da Saúde (2006) Guia Alimentar para a população brasileira: promovendo a alimentação saudável. Secretaria de Atenção à Saúde, Brasília

    Google Scholar 

  36. 36.

    Kipnis V, Midthune D, Buckman DW et al (2009) Modeling data with excess zeros and measurement error: application to evaluating relationships between episodically consumed foods and health outcomes. Biometrics 65(4):1003–1010

    PubMed  PubMed Central  Google Scholar 

  37. 37.

    de Andrade SC, de Azevedo Barros MB, Carandina L et al (2010) Dietary quality index and associated factors among adolescents of the state of Sao Paulo, Brazil. J Pediatr 156(3):456–460.

    Article  PubMed  Google Scholar 

  38. 38.

    Godoy FdC, SCd A, Morimoto JM et al (2006) Índice de qualidade da dieta de adolescentes residentes no distrito do Butantã, município de São Paulo, Brasil. Revista de Nutrição 19:663–671

    Google Scholar 

  39. 39.

    de Assumpção D, Barros MB, Fisberg RM et al (2012) Diet quality among adolescents: a population-based study in Campinas, Brazil. Rev Bras Epidemiol 15(3):605–616

    PubMed  Google Scholar 

  40. 40.

    de Andrade SC, Previdelli ÁN, Cesar CLG et al (2016) Trends in diet quality among adolescents, adults and older adults: a population-based study. Prev Med Rep 4:391–396

    PubMed  PubMed Central  Google Scholar 

  41. 41.

    Monteiro LS, Rodrigues PRM, Veiga, GVd et al (2016) Diet quality among adolescents has deteriorated: a panel study in Niterói, Rio de Janeiro State, Brazil, 2003–2008. Cadernos de Saude Publica 32 (12):e00124715

    PubMed  Google Scholar 

  42. 42.

    Goodwin DK, Knol LK, Eddy JM et al (2006) Sociodemographic correlates of overall quality of dietary intake of US adolescents. Nutr Res 26(3):105–110

    CAS  Google Scholar 

  43. 43.

    Tek N, Yildiran H, Akbulut G et al (2011) Evaluation of dietary quality of adolescents using healthy eating index. Nutr Res Pract 5(4):322–328.

    Article  Google Scholar 

  44. 44.

    Golley RK, Hendrie GA, McNaughton SA (2011) Scores on the dietary guideline index for children and adolescents are associated with nutrient intake and socio-economic position but not adiposity. J Nutr 141(7):1340–1347

    CAS  PubMed  Google Scholar 

  45. 45.

    Claro RM, Santos MAS, Oliveira-Campos M (2014) Body image and extreme attitudes toward weight in Brazilian schoolchildren (PeNSE 2012). Revista Brasileira de Epidemiologia 17:146–157

    PubMed  Google Scholar 

  46. 46.

    Alvarenga MdS, Lourenço BH, Philippi ST et al (2013) Disordered eating among Brazilian female college students. Cadernos de saude publica 29(5):879–888

    Google Scholar 

  47. 47.

    Kuschnir MC, Bloch KV, Szklo M et al (2016) ERICA: prevalence of metabolic syndrome in Brazilian adolescents. Rev Saude Publica.

    Article  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Bloch KV, Klein CH, Szklo M et al (2016) ERICA: prevalences of hypertension and obesity in Brazilian adolescents. Rev Saude Publica.

    Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Diethelm K, Jankovic N, Moreno LA et al (2012) Food intake of European adolescents in the light of different food-based dietary guidelines: results of the HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) Study. Public Health Nutr 15(3):386–398.

    Article  PubMed  Google Scholar 

  50. 50.

    Kalkwarf HJ, Khoury JC, Lanphear BP (2003) Milk intake during childhood and adolescence, adult bone density, and osteoporotic fractures in US women. Am J Clin Nutr 77(1):257–265

    CAS  PubMed  Google Scholar 

  51. 51.

    Greer FR, Krebs NF (2006) Optimizing bone health and calcium intakes of infants, children, and adolescents. Pediatrics 117(2):578–585

    PubMed  Google Scholar 

  52. 52.

    Guo J, Astrup A, Lovegrove JA et al (2017) Milk and dairy consumption and risk of cardiovascular diseases and all-cause mortality: dose–response meta-analysis of prospective cohort studies. Eur J Epidemiol 32:269–287 (Springer)

    CAS  PubMed  PubMed Central  Google Scholar 

  53. 53.

    Thorning TK, Bertram HC, Bonjour J-P et al (2017) Whole dairy matrix or single nutrients in assessment of health effects: current evidence and knowledge gaps. Am J Clin Nutr 105(5):1033–1045

    CAS  PubMed  Google Scholar 

  54. 54.

    Drehmer M, Pereira MA, Schmidt MI et al (2016) Total and full-fat, but not low-fat, dairy product intakes are inversely associated with metabolic syndrome in adults. J Nutr 146(1):81–89

    PubMed  Google Scholar 

  55. 55.

    Fernández-Ortega M (2008) Consumo de fuentes de calcio en adolescentes mujeres en Panamá. Archivos Latinoamericanos de Nutrición 58(3):286

    PubMed  Google Scholar 

  56. 56.

    Malik VS, Popkin BM, Bray GA et al (2010) Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care 33(11):2477–2483.

    Article  PubMed  PubMed Central  Google Scholar 

  57. 57.

    World Health Organization (2015) Guideline: sugars intake for adults and children. World Health Organization, Geneva.

    Google Scholar 

  58. 58.

    Malta DC, Andreazzi MAR, Oliveira-Campos M et al (2014) Trend of the risk and protective factors of chronic diseases in adolescents, National Adolescent School-based Health Survey (PeNSE 2009 e 2012). Revista Brasileira de Epidemiologia 17:77–91

    PubMed  Google Scholar 

  59. 59.

    Béghin L, Dauchet L, De Vriendt T et al (2014) Influence of parental socio-economic status on diet quality of European adolescents: results from the HELENA study. Br J Nutr 111(7):1303–1312.

    CAS  Article  PubMed  Google Scholar 

  60. 60.

    Oliveira JS, Barufaldi LA, Abreu GeA et al (2016) ERICA: use of screens and consumption of meals and snacks by Brazilian adolescents. Rev Saude Publica 50 Suppl 1.

  61. 61.

    Batis C, Aburto TC, Sánchez-Pimienta TG et al (2016) Adherence to dietary recommendations for food group intakes is low in the Mexican population. J Nutr 146(9):1897S–1906S

    CAS  PubMed  Google Scholar 

  62. 62.

    Wang YC, Bleich SN, Gortmaker SL (2008) Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988–2004. Pediatrics 121(6):e1604–e1614

    PubMed  Google Scholar 

  63. 63.

    Levy-Costa RB, Sichieri R, Pontes NdS et al (2005) Household food availability in Brazil: distribution and trends (1974–2003). Revista de Saude publica 39(4):530–540

    PubMed  Google Scholar 

  64. 64.

    Jaime PC, Stopa SR, Oliveira TP et al (2015) Prevalence and sociodemographic distribution of healthy eating markers, National Health Survey, Brazil 2013. Epidemiologia e Serviços de Saúde 24 (2):267–276

    Google Scholar 

  65. 65.

    Ruel MT (2003) Operationalizing dietary diversity: a review of measurement issues and research priorities. J Nutr 133(11):3911S–3926S

    CAS  PubMed  Google Scholar 

  66. 66.

    Forrestal SG (2011) Energy intake misreporting among children and adolescents: a literature review. Matern Child Nutr 7(2):112–127

    PubMed  Google Scholar 

  67. 67.

    Livingstone MBE, Robson P, Wallace J (2004) Issues in dietary intake assessment of children and adolescents. Br J Nutr 92(S2):S213–S222

    CAS  PubMed  Google Scholar 

  68. 68.

    Tooze JA, Kipnis V, Buckman DW et al (2010) A mixed-effects model approach for estimating the distribution of usual intake of nutrients: The NCI method. Stat Med 29(27):2857–2868

    PubMed  Google Scholar 

  69. 69.

    Willett W (2013) Nutritional Epidemiology: Monographs in epidemiology and biostatistics, vol 40, 3rd edn

  70. 70.

    Dodd KW, Guenther PM, Freedman LS et al (2006) Statistical methods for estimating usual intake of nutrients and foods: a review of the theory. J Am Diet Assoc 106(10):1640–1650.

    Article  PubMed  Google Scholar 

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This work was supported by the Brazilian Funding Authority for Studies and Projects (FINEP) (Grant number 01090421) and the Brazilian National Council of Technological and Scientific Development (CNPq) (Grant numbers 565037/2010-2, 405009/2012-7, 457050/2013-6), and DBR received the Spouse Education Fund (SEF) grant from the Community Committee for International Students of Stanford University Bechtel International Center (CA, USA) to participate in a Stata software course. FINEP, CNPq, and SEF had no role in the design, analysis or writing of this article. DBR would like to acknowledge the Spouse Education Fund (SEF) grant provided by the Community Committee for International Students of Stanford University (CA, USA). The authors gratefully acknowledge Inge Huybrechts from the HELENA study (Healthy Lifestyle in Europe by Nutrition in Adolescence) for her help in the calculation of the diet index and Eliseu Verly Júnior for being a consultant.

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Correspondence to Débora Barbosa Ronca.

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The present study was approved by the appropriate ethics committee, and all procedures performed were in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments.

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Ronca, D.B., Blume, C.A., Cureau, F.V. et al. Diet quality index for Brazilian adolescents: the ERICA study. Eur J Nutr 59, 539–556 (2020).

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  • Diet quality
  • Dietary index
  • Dietary patterns
  • Nutrition assessment
  • Adolescents