Assessment of the Quality of Hypoenergetic Diet in Overweight Women

1Universidade Federal do Rio de Janeiro – Programa de Pós-graduação (Mestrado) em Cardiologia – Rio de Janeiro, RJ – Brazil 2Universidade Federal do Rio de Janeiro – Instituto Josué de Castro Rio de Janeiro, RJ – Brazil 3Universidade Federal do Rio de Janeiro – Instituto de Estudos em Saúde Coletiva – Rio de Janeiro, RJ – Brazil 4Universidade Federal do Rio de Janeiro – Hospital Universitário Clementino Fraga Filho – Serviço de Cardiologia – Rio de Janeiro, RJ – Brazil


Introduction
The number of deaths worldwide attributable to an unhealthy diet increased from 8.5 million (95% CI: 7.9 to 9.2) in 1990 to 12.5 million (95% CI: 11.7 to 13.3) in 2010, mainly due to consumption of diets low in fruits, nuts/ seeds and vegetables 1 .This has resulted in increased body mass index (BMI) of 0.4 mg/kg 2 /decade (95% CI: 0.2-0.6)for men, and 0.54 mg/kg 2 /decade (95% CI: 0.3-0.7)for women, from 1980 to 2010.That probably happened due to a greater access to caloric diets rich in ultra-processed food products and physical inactivity 2 .
The tools for assessing dietary patterns have several limitations inherent to the complexity of comparing different living habits in various socio-economic and cultural environments.The diet quality index revised for the Brazilian population (DQI-R) aims to assess the combination of different types of food and nutrients, measuring dietary risk factors for non-communicable chronic diseases 3 .The evaluation of ultra-processed food products with excessive fat, sugar and salt concentrations, high energy density and shortage of dietary fibers contribute in the characterization of unhealthy diets 4 .Diet Quality in Women Int J Cardiovasc Sci.2015;28(3):244-250 Original Manuscript

• VAI -visceral adiposity index • VLDL-c -very low density lipoprotein • WC -waist circumference • WHtR -waist-to-height ratio
It is a challenge to determine healthy eating patterns, but also an opportunity to reduce the global burden of noncommunicable diseases, especially in socioeconomic strata where groups that are more vulnerable are found, such as groups presenting low-income and education levels 5 .However, there is no known tool developed with the Brazilian population to assess the qualitative changes of diets recommended for reducing non-communicable chronic diseases 6 .
The purpose of this study was to evaluate the effect of the hypoenergetic diet, based on the diet quality index revised for the Brazilian population (DQI-R) and the consumption of ultra-processed food products (UPP) in women with overweight.

Methods
This is a 6-months clinical trial conducted with a convenience sample from the city of São Gonçalo, in the state of Rio de Janeiro.Steps undertaken: gathering of general information about the volunteers; application of the 24-hour dietary recall survey (R24h); anthropometric, biochemical evaluation; and blood pressure measurement.Each volunteer received an individualized hypoenergetic diet plan and a replacement food list.The volunteers had to attend monthly appointments, where anthropometric, biochemical and dietary evaluations were performed.
The anthropometric evaluation measured the body mass (BM) in kilograms (kg) and height in meters (m), using a Welmy digital platform scale with coupled stadiometer (Welmy ® , Santa Bárbara d'Oeste, São Paulo, Brazil).The body mass index (BMI) was calculated by dividing the body mass (kg) by the height (m) squared 6 .Waist circumference (WC) was measured at the midpoint between the iliac crest and the last rib, u s i n g a n i n e l a s t i c t a p e 7 .N e c k circumference (NC) was measured with the head positioned in the Frankfurt horizontal plane, the upper edge of the tape placed under the cricoid cartilage, and applied perpendicularly around the neck 8 .The waist-to-height ratio (WHtR) was determined by the ratio of the waist circumference (cm) by the height (cm) 9 .
Blood pressure (BP) was measured by a Missouri Mikatos aneroid sphygmomanometer (Mikatos, Embu das Artes, São Paulo, Brazil), with armband suitable for obese patients, and stethoscope for auscultation after the volunteer has remained seated for at least five minutes 11 .
The calculation to determine the total energy value (TEV) was based on the recommendations of the Dietary References Intake 12 specific to females.A 1.0 physical activity factor was taken into account for all volunteers, representing a sedentary lifestyle.Subsequently, 513 kcal were deducted from the TEV, according to the VENTA method (energy value of adipose tissue), which corresponds to a loss of approximately 2 kg per month: protein 15-20% of TEV, carbohydrate 55-60% of TEV, lipids 20-30% of TEV, and the specific distribution of fatty acids.
Blood samples were collected after 12-hours overnight fasting.Serum concentrations of total cholesterol, HDL-c (high-density lipoproteins), triglycerides, glucose and uric acid were determined by enzymatic colorimetric method in a LabMax 240 automated biochemical analyzer (Labtest Diagnóstica S.A., Brazil).LDL-c (low-density lipoproteins) and VLDL-c (very low-density lipoproteins) concentrations were calculated by the Friedewald formula 13 .
Data on food consumption was obtained by the analysis of R24h at baseline after six months, using the Food Processor software, version 7.2 (Esha Research, Salem, USA).
The diet quality index revised for the Brazilian population (DQI-R) 3 and the consumption of ultra-processed food Diet Quality in Women Int J Cardiovasc Sci.2015;28(3):244-250 Original Manuscript products (UPP) and additives (sugar and sodium) 4 were used to evaluate the diet quality.
The DQI-R was evaluated considering the total score and components (food groups and nutrients).The DQI-R total score was dichotomized above and below the 75 percentile (P75).The DQI-R ≥P75 value was considered appropriate because it represents the quartile with the highest score, indicating better diet quality, an adequate diet; values below this quartile are equivalent to an inadequate diet.
The evaluation of ultra-processed food products and additives was performed using the R24h, where the consumption of certain food products was quantified, We observed that the hypoenergetic diet caused a significant reduction in BM, BMI, NC, WC, WHtR, VAI, systolic BP, in glucose, triglycerides and VLDL-c concentrations, also demonstrating the effect of dietary treatment on anthropometric parameters, biochemical biomarkers, and on blood pressure (Table 1).The quality of diet improved in both groups with significant reduction in the consumption of proteins, total lipids, fatty acids and sodium in the adequate diet (classified according to the DQI-R); and there was a reduction in energy, glucose, VLDL-C and DBP in the group following an inadequate diet (classified according to the DQI-R) (Table 2).
There was a significant decrease in the consumption of UPP, such as soft drinks, instant noodles, processed juices, and added sugar foods (Table 3).

Discussion
At the end of the study, it was found that the adherence to the hypoenergetic diet caused a significant reduction in BM, BMI, NC, WC, WHtR, BAI, SBP, and in the concentrations of glucose, triglycerides and VLDL-C.Valle et al. 14 , in a study with 20 overweight women with a mean age of 23.8 years, randomized into hypoenergetic diet and control groups for 12 weeks, also observed a significant reduction in the BM, BMI, triglycerides and VLDL-C in the group following the hypoenergetic diet.
This study showed that even with a small, but significant, loss of 3.0% of body mass, most parameters analyzed were reduced, a situation different from that observed in another study that states that one should lose at least 5.0% of BM to change these parameters 15 .
By analyzing the data grouped according to the DQI-R and by the analysis of ultra-processed food products, it is noticeable that the hypoenergetic diet improved the eating patterns even in individuals with low educational and socioeconomic levels, who followed an inadequate diet.This finding was different from that observed in 660 climacteric women in an outpatient care center in Southern Brazil, where researchers reported that the dietary pattern was significantly influenced by age, educational level and income 16 .
The difficulty in assessing the healthy eating patterns has resulted in the creation of simple and easy-to-use tools for application in a population or at individual level, in order to track or monitor the implementation of dietary changes for primary prevention.Their use, however, should be individualized for each population under study 17 .
This study showed that the assessment of diet quality cannot be verified by DQI-R dichotomized into adequate or inadequate diets.Furthermore, the assessment of UPP consumption seemed to better explain the observed changes in anthropometric parameters and biomarkers of overweight women following the hypoenergetic diet (Table 2).already observed among Brazilians of low consumption of fruits and vegetables, and the increased consumption of processed and industrialized food products.They also pointed out the difficulty of showing the benefits of adherence to the diet by this instrument to assess change in its quality 19 .
There is growing evidence that consumption of large amounts of high-calorie soft drinks can inhibit biological mechanisms responsible for satiety responses, leading to an excessive energy consumption, and thus resulting in the increased excess of body mass 6 .According to data from the Household Budget Survey, the consumption of soft drinks in southeastern Brazil was the eighth most prevalent item among the items analyzed 20 .It was also reported that the relative share of fats in the diet of Brazilian families is growing, since 82.0% of study participants showed excessive consumption of saturated fats 20 .The assessment of diet quality by DQI-R showed a significant reduction in the consumption of proteins and lipids.However, it was unable to demonstrate the differences in the classification proposed in the study of Previdelli et al. 3 According to Malik et al. 21, the consumption of sugarsweetened beverages can be a key contributor to the epidemic of overweight and obesity, by virtue of these beverages' high-added sugar content, low satiety, and incomplete compensation for total energy.This may explain why the assessment of UPP has showed improved hypoenergetic diet quality in overweight women.
This study has two limitations: the small number of participants, and the fact that the women who volunteered to only one cultural, socioeconomic strata.
Both tools used to assess diet quality had limitations when applied to check changes of the hypoenergetic diet in anthropometric and biochemical parameters in overweight women.The combination of these could be an alternative for the Brazilian population.Further research in different populations is necessary to validate this hypothesis.

Conclusion
The hypoenergetic diet reduced anthropometric and biochemical parameters and these changes were not explained by DQI-R, dichotomized as adequate or inadequate diet, but by the evaluation of UPP and additives, showing the limitations of tools for diet quality assessment.

Potential Conflicts of Interest
No relevant potential conflicts of interest.

Sources of Funding
This study was partially funded by the Coordination for the Improvement of Higher Education (CAPES).

Academic Association
This manuscript is part of the Master's thesis of Elizabeth de Paula Franco, from the Federal University of Rio de Janeiro (UFRJ).
-parametric tests were employed to obtain results.The Wilcoxon test was used for time comparison (start time and end time) of the same group, and the Mann-Whitney test was used for analysis between groups.The statistical significance value of p <0.05 was considered.
as instant chocolate mix, margarine, cookies, whole milk, sausages, soft drinks, chocolate candies, added sugar food, instant noodles, vegetable oil, sodium and processed juices, before and after nutritional intervention.All statistical analyzes were conducted using SPSS version 21 (SPSS Inc., Chicago, IL) (Statistical Package for the Social Science).The results were expressed in percentage, average and standard deviation, and median.The chi-square test was used for categorical variables.According to the Kolmogorov-Smirnov normality test, most variables has not been normally distributed; therefore, non

Table 3 Ultra-processed food products and additives consumed by volunteers during the study
1Wilcoxon test.Statistically significant p <0.05