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Dietary Sources of Sodium Intake in Brazil in 2008-2009
RESEARCH Research and Professional Briefs
Dietary Sources of Sodium Intake in Brazil in 2008-2009 Amanda de Moura Souza, PhD, MPH; Ilana Nogueira Bezerra, PhD, MPH; Rosangela Alves Pereira, PhD, MPH; Karen Eileen Peterson, ScD; Rosely Sichieri, PhD, MD ARTICLE INFORMATION
ABSTRACT
Article history:
Information on the main dietary sources of sodium is essential for developing public health strategies to reduce sodium intake. This study aimed to describe sodium intake according to sex, age, and income and identify the main dietary sources of sodium in Brazil. In total, 34,003 subjects aged 10 years and older participated in the first Brazilian National Dietary Survey, conducted in 2008-2009. Food was classified according to the sodium profile into 31 groups based on a 1-day food record. The daily per capita intake of sodium (mg/day) and sodium density (mg/100 g) were estimated for each food group and stratified by sex, age, and per capita income quartile. The average daily intake of sodium was 3,190 mg/day. The sodium density of the diet increased with age and income (P<0.05). Food groups with the highest densities for both sexes and across all income quartiles included salty preserved meats (997 mg/100 g), processed meats (974 mg/100 g), cheeses (883 mg/100 g), crackers (832 mg/100 g), sandwiches (800 mg/100 g), pizza (729 mg/100 g), and breads (646 mg/100 g), as well as oils, spreads, sauces, and condiments (804 mg/100 g). Altogether, these food groups contributed to 811 mg/day of sodium, which is more than half of the recommended daily sodium intake. Mean sodium intake in Brazil exceeded the tolerable upper intake level of 2,300 mg/day. Processed food contributed to half of the recommended intake and should be targeted by future public health policies aiming at reducing total sodium intake.
Accepted 22 April 2013 Available online 3 July 2013
Keywords: Sodium intake Dietary survey Brazil Copyright ª 2013 by the Academy of Nutrition and Dietetics. 2212-2672/$36.00 http://dx.doi.org/10.1016/j.jand.2013.04.023
J Acad Nutr Diet. 2013;113:1359-1365.
D
URING THE PAST SEVERAL DECADES, SODIUM intake in median and high-income countries has been excessive, varying from 3,600 to 4,800 mg/ day.1 These values exceed the tolerable upper intake levels of 2,200 mg/day (for individuals aged 9 to 13 years) and 2,300 mg/day (for individuals aged 13 years and older) of sodium recommended by the US Dietary Reference Intakes.2 A high intake of sodium is a public health concern because excessive consumption is associated with development of high blood pressure.3 For example, a population-based study conducted in Canada estimated that 30% of hypertension is related to high sodium consumption.4 In Brazil, approximately 23% of adults were medically diagnosed with hypertension (blood pressure 140/90 mm Hg) in 20105 and, in 2007, 3.7% of all deaths were attributed to high blood pressure.6 The prevalence of excessive sodium intake in the first Brazilian National Dietary Survey ranged from 71% in girls (14 to 18 years of age) to 89% in adult men (19 to 59 years of age).7 Few countries have collected nationally representative data on the dietary sources of sodium, which is fundamental for developing policies to reduce salt intake.8 Such information could help educate people on the importance of appropriate sodium consumption, as well as help develop policies for reducing sodium levels in specific food products and indicating sodium content in food product labeling. ª 2013 by the Academy of Nutrition and Dietetics.
This study aimed to describe sodium intake according to sex, age, and income, and identify the main dietary sources of sodium in Brazil.
METHODS This study analyzes data obtained in the first nationwide dietary survey conducted in Brazil by the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatistica) along with the 2008-2009 Household Budget Survey.9 Food consumption of a representative sample of the Brazilian population 10 years of age or older (subsampled from the households investigated in the Household Budget Survey) was ascertained by two nonconsecutive food diaries obtained on predetermined days spanning 1 week.
Subjects The households in the main sample were selected by a twostage complex cluster sampling design, with the census tracts as primary sampling units and households as secondary sampling units. Primary sample units were selected by systematic sampling with proportional probability to the number of households based on the 2000 Brazilian Demographic Census. Primary sample units were stratified by socioeconomic and geographic strata, and JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
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RESEARCH Food groups
Description
Beans and legumes
Beans, pea, soy meat, and other legumes
Breads
White and whole-wheat breads and bread toasts
Breakfast cereals
Ready-to-eat and cooked cereals
Cakes and cookies
All cakes, sweets cookies, and filling cookies
Cheeses
Mozzarella, cottage, cheddar, and others
Corn/corn dishes
Corn, corn meals, corn flour, polenta, and other corn dishes
Crackers
Crackers and chips (potato/corn)
Deep-fried and baked snacks
Salty pastries, chicken/meat/cheese patties, deep fried snacks, and others
Desserts and sugar
Milk and fruit desserts, pies, sweet pastries, candies, honey, sugar
Eggs
Egg and egg dishes
Fish and shellfish
Fish/shellfish and mixtures with grains and/or vegetables
Fruits
All fruits and salad fruits (does not include fruit juices)
Green leaf vegetables
Lettuce, spinach, rucola, and others
Meat/meat dishes
Meat and mixtures with grains and/or vegetables
Milk and dairy
Fluid milk, yogurt, chocolate milk (does not include milk dessert)
Nuts
Peanuts, cashew nuts, almonds, and others
Oils, spreads, sauces, and condiments
Vegetable oils, olive oil, butter, margarine, mayonnaise, and others
Other beverages
Fruit juices, fruit drinks, coffee, tea, and alcoholic beverages
Other tubers
Manioc, yam, and tuber products
Other vegetables
Tomato, pumpkin, carrots, squash, and others
Pasta/pasta dishes
Spaghetti, ravioli, lasagna
Pizza
Pizzas and calzones
Pork/pork dishes
Pork and mixtures with grains and/or vegetables
Potato
All potato items other than potato chips
Poultry/poultry dishes
Poultry and mixtures with grains and/or vegetables
Processed meats
Ham, luncheon meats, frankfurters
Rice/rice dishes
White rice, rice with legumes, sushi, and other rice dishes
Salty preserved meats/fish
Meats preserved with high amount of salt and salty codfish
Sandwiches
Hamburgers, cheeseburgers, egg/cheese/ham sandwiches
Soft drinks
Soft drinks
Soups
Soups and broths
Figure. Food groups in 2008-2009 Brazilian National Dietary Survey.
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RESEARCH households were selected by simple random sampling. Twenty-five percent of the Household Budget Survey participants (approximately 14,000 households) were randomly selected. The survey response rate was 81%. The National Dietary Survey was designed to collect information on the food consumption of all family members older than 10 years of age (N¼34,003). The research protocol was approved by the Committee of Ethics in Research of the Institute of Social Medicine (CAAE 0011.0.259.000-11).
Dietary Intake In this analysis, sodium intake was estimated based on food and beverage consumption data obtained in the first of the two nonconsecutive food records. Participants described all food and beverages consumed, in addition to the following: the cooking method (eg, raw, cooked, fried, with tomato sauce) used for specific items (meats, poultry, fish, and vegetables); the amount of food consumed; and the time and place where food and beverages were consumed. The participants received a manual with instructions for completing the survey, as well as photographs of household utensils and containers (tableware, cans, and bottles) to assist in the estimation of food portions. Food records were reviewed in personal interviews conducted in the households by trained interviewers who probed the participants on usually forgotten foods and sought to clarify doubts and incomplete information in the records. In addition, for food records with less than five items or presenting periods longer than 3 hours without any reported food intake, the respondents were asked to either confirm the information or to provide data on consumed foods and/or beverages. Data entry was performed using specific software developed by the Brazilian Institute of Geography and Statistics. Partial analyses were performed during data collection to check data quality. The 2-day register was tested against doubly labeled water in a study performed among adults from Duque de Caxias, Rio de Janeiro. The estimation of energy expenditure by doubly labeled water indicated an underestimation of 17% of energy intake.9
The sodium content in foods and beverages was estimated using the Nutrition Data System for Research software version 2008,10 the Brazilian Food Composition Table,11 and Brazilian studies on regional foods.12 In order to identify the major food sources of sodium, the 1,971 items (food and beverages) reported in the survey were classified into 31 food groups based on sodium profile (Figure).
Statistical Analysis Trends in sodium intake and sodium density across income levels and age strata were analyzed using linear regression models. Sodium intake and sodium density variables were log-transformed in order to approximate a normal distribution. Monthly per capita household income was calculated as the total household income divided by the number of household members and categorized into quartiles: US $124; >US $124, and US $240; >US $240, and US $458; and >US $458 (per capita, per month). Differences between food groups mean sodium density (mg/100 g) across age, sex, and income groups were determined based on overlapping confidence intervals for mean values. All statistical analyses were performed using survey procedures from the Statistical Analysis System (version 9.3, 2011, SAS Institute Inc) and accounted for weighting and the multi-stage sampling design.
RESULTS AND DISCUSSION This is the first study to describe the main contributors to sodium intake in the Brazilian diet using data from a nationwide dietary survey. Mean daily intake of sodium was estimated at 3,190 mg/day and exceeded the tolerable upper intake level in strata. Sodium consumption was higher among male subjects and decreased with age among female subjects, but, for male subjects, an inverted V-shaped association between sodium consumption and age was observed (Table 1). No difference in intake was observed with income among women, whereas an inverted J-shaped association between intake and income was observed for men (Table 1).
Table 1. Sodium daily intake (mg/day) and standard error according to age group and income level by sex among Brazilian National Dietary Survey respondents, 2008-2009 Age Group Elderly
P value
3,66628.0
3,22946.9
<0.01a
2,82820.8
2,64448.0
<0.01b
Total
Adolescent
Adults
Males
3,58024.7
3,52349.5
Females
2,82618.2
2,94937.3
1st
2nd
Males
3,42544.8
3,65644.1
3,69947.3
3,56354.6
<0.01a
Females
2,80430.5
2,83234.1
2,85535.5
2,82540.9
0.40b
mg/daystandard error
Income Quartile 3rd
4th
mg/daystandard error
a
Quadratic association. Linear trend based on regression analysis.
b
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Men 10-19 y Food groups
%
Beans and legumes
15.2
Breads
11.0
mg/100 g
%
225.3
15.6
226.0
15.0
225.6
12.6
646.6
10.6
647.6a
10.3
647.7
11.2
a
abc
0.0
322.5
2.1
216.3
Cheeses
0.8
740.9bc 259.9
a a
Crackers
2.6
822.8
Deep-fried and baked snacks
1.4
380.8
Desserts and sugar
0.7
Eggs
10-19 y
mg/100 g
Cakes and cookies
1.8
60D y
%
Breakfast cereals
Corn/corn dishes
Women
20-59 y
70.0c abc
mg/100 g
%
20-59 y
mg/100 g
60D y
%
mg/100 g
%
mg/100 g
224.5
12.8
225.7
12.3
225.2
646.9
11.4
643.2a
11.1
645.2
ad
ae
0.0
100.7
0.0
113.7
0.1
255.8
0.0
203.4
0.1
105.8
0.9
159.9
0.9
162.6
2.3
208.2
1.2
164.6
1.0
152.0
1.8
862.9f
3.1
1,073.5
0.9
700.4dg
2.4
884.1
3.6
992.3
1.7
266.0
1.8
260.7
1.8
275.2a
1.7
267.7
1.7
260.4
a
1.5
841.7
1.4
853.5
2.9
787.5
2.0
842.6
2.7
849.5
1.0
360.7
0.8
412.7
1.6
341.6
1.2
371.6
0.9
378.5
0.4
68.6f
0.3
53.9
0.9
68.2
0.6
70.7
0.4
59.5
1.2
316.9
1.1
310.7a
1.2
314.1ad
1.0
310.1e
0.9
296.0a
1.3
330.1
Fish and shellfish
3.3
439.4
3.4
437.6
3.5
440.1
2.8
440.3
3.4
439.2
3.9
439.3
Fruits
0.0
1.4
0.0
1.2
0.0
1.3
0.0
1.3
0.0
1.3
0.1
1.3
Green vegetables
0.2
61.9
0.5
69.7
0.6
76.6
0.3
59.7
0.7
70.4
0.8
74.1
Meat/meat dishes
8.2
409.0
9.3
403.0
8.8
406.7
8.1
412.9
8.7
407.3
7.6
411.0
Milk and dairy
2.5
44.1
1.7
38.3
3.5
53.8
3.2
48.5
2.6
41.2
4.3
49.8
Nuts
0.0
42.4c
0.0
67.3a
0.0
241.4f
0.0
101.4g
0.0
205.6a
0.0
88.0
Oils, spreads, sauces, and condiments
1.8
802.2
1.8
806.2
1.6
815.5
1.9
828.2
1.9
802.3
1.8
763.9
Other beverages
0.9
4.6
1.3
4.3
1.2
5.4
1.2
5.2
1.1
4.5
1.2
4.0
ab
f
ad
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Other cereals and tubers
0.3
155.6
0.7
193.7
1.0
166.7
0.5
210.2
0.7
200.6
1.4
182.6
Other vegetables
0.4
112.6
0.5
133.1
0.6
155.9
0.5
160.6
0.5
133.3e
0.4
172.6
Pasta/pasta dishes
2.9
240.1
3.1
234.4
2.3
240.8
3.3
239.3
3.2
237.1
2.1
237.4
Pizza
0.6
729.5abc
1.3
734.2f
0.1
752.4a
1.5
718.3a
1.3
727.4
0.3
719.4a
Pork/pork dishes
0.5
239.9
0.8
258.1
0.7
270.2
0.6
247.4
0.7
263.2
0.7
271.8
Potato
1.2
312.2c
1.6
303.5
1.6
285.4
1.8
308.4d
1.8
302.2
1.6
285.7
Poultry/poultry dishes
4.5
416.0
4.9
415.8
4.6
419.1
4.9
417.5
5.2
416.7
4.7
417.8
Processed meats
2.9
961.7
2.9
975.2
2.9
1,044.9
2.7
989.7
2.3
959.0
1.8
978.0
Rice/rice dishes
20.8
381.2
22.0
382.5
20.3
384.0
19.0
381.9
19.4
382.2
18.9
383.2
2.3
1,262.0
1.7
954.2
1.8
724.5a
1.7
1,153.5
1.8
979.6
Salty preserved meats
1.5 976.8a (continued on next page)
RESEARCH
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Table 2. Percentage of total sodium intake (%) and sodium density (mg/100 g) provided by food groups according to sex and age among Brazilian National Dietary Survey respondents, 2008-2009
353.9a
7.0 0.1
10.7
784.3 1.5
7.2
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P values <0.05 comparisons for density: a In each age and sex groups. b Adolescent and adult males. c Adolescent and elderly males. d Adolescent and elderly females. e Adult and elderly females. f Adult and elderly males. g Adolescent and adult females.
5.8 0.2
6.4
349.3
0.3
8.3
6.1 5.7
348.9 4.4
0.2
5.1 Soups
5.9 0.2 Soft drinks
348.9
0.1
340.6a
6.4
341.7
e
798.2 3.0 743.2a 3.9 835.3 1.8 815.1 3.2 811.1a 4.2 Sandwiches
mg/100 g
60D y
% 20-59 y
mg/100 g mg/100 g mg/100 g mg/100 g mg/100 g % Food groups
10-19 y
%
20-59 y
%
60D y
%
10-19 y
%
Women Men
Table 2. Percentage of total sodium intake (%) and sodium density (mg/100 g) provided by food groups according to sex and age among Brazilian National Dietary Survey respondents, 2008-2009 (continued)
RESEARCH Similar results were observed in the United States (3,330 mg/day) 13 and Canada (3,098 mg/day).14 Mean daily intake of sodium was higher among American men than among American women and sodium consumption was above the tolerable upper intake level for all individuals, except for children aged 2 to 5 years.13 In the US population, the differences in sodium intake across all age and sex groups were explained by differences in energy consumption,13 and in Brazil, sodium intake among men adjusted for energy intake remained higher than that among women. After adjusting for energy intake, sodium consumption was positively associated with age and inversely associated with income level for both sexes. These associations could be explained by differences in food consumption profile across age and income groups, for example, the positive association between age and sodium indicate that elderly individuals choose foods with higher sodium content. The highest percentage of sodium intake for all age and sex groups was attributed to rice/rice dishes, beans, and breads (Table 2). These food groups are considered important sources of sodium because of their frequent consumption. Based on the first day of food record, 86% of the participants reported the consumption of rice and 74% of them reported beans intake. However, traditional Brazilian foods, such as rice and beans, have low sodium density (382 mg/100 g and 226 mg/100 g, respectively). Foods with sodium densities >600 mg/100 g included salty preserved meats (997 mg/100 g), processed meats (974 mg/ 100 g), cheeses (883 mg/100 g), crackers (832 mg/100 g), sandwiches (800 mg/100 g), pizza (729 mg/100 g), and breads (646 mg/100 g), as well as oils, spreads, sauces, and condiments (804 mg/100 g). Altogether, these eight food groups contributed to 25% (811 mg/day) of the average daily sodium intake, amounting to nearly 40% of the tolerable upper intake level (2,300 mg/day) for adults (Table 2). More specifically, they contributed to 26%, 25%, and 23% of total sodium consumption among adolescent, adult, and elderly male subjects, respectively, and 27%, 26%, and 25% among adolescent, adult, and elderly female subjects, respectively (Table 2). Except for rice and beans, the contributors to sodium intake are similar to the findings from surveys in developed countries. Population-based study from Canada (The Canadian Community Health Survey 2.2, using one 24-hour recall, found that breads and processed meats were the main dietary source of sodium across all age groups (1 to 8 years, 9 to 18 years, and 19 years or older); however, vegetables (excluding canned or pickled vegetables and potatoes) were the third highest contributing food source to sodium intake among female subjects aged 19 years or older.14 In the United States, the 2007-2008 National Health and Nutrition Examination Survey, based on one 24-hour recall, found that breads, salad dressings, cheeses, and soups were major dietary sources of sodium.13 Among British adults aged 19 to 64 years, breads, fats, cheeses, sauces, chips, and meat products were the main contributors.15 No other Latin American countries have published reports on the main food sources of sodium using national representative samples. The 2005 National Survey on Nutrition and Health in Argentina, which investigated salt consumption among children younger than 5 years of age and female subjects aged 10 to 49 years, reported an average salt intake of 3.1 g/day from processed food consumption among female JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
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RESEARCH subjects aged 10 to 49 years16 more than half of the tolerable upper limit of intake level. Our analysis stratified by income showed a decline in sodium intake from sources such as eggs, meat/meat dishes, salty preserved meats, as well as oils, spreads, sauces, and condiments in the highest income quartile. For items such as breakfast cereals and salty preserved meats, density is reduced by half. Reducing salt intake is one of the World Health Organization strategies to prevent noncommunicable diseases.17 These strategies include monitoring and evaluating salt consumption amounts, identifying dietary sources of salt, reducing the amount of salt added to food, and introducing programs to increase consumer knowledge and healthy behavior that lead to reduced dietary salt intake.17 In Brazil, the Ministry of Health and the Brazilian Association of Food Industry have established a partnership to reduce the sodium content of processed foods.18 These changes are expected to result in 30% reductions in the sodium content of industrialized pasta and 10% in breads and white buns.18 However, because the industry recognizes the importance of regulating sodium intake, changes should be applied, as soon as possible, to processed foods such as processed meats, which constitute the food group with the second highest sodium density. A limitation of this study was that we could not estimate the amount of table salt added to food. Data from the 2002-2003 Brazilian Household Budget Survey showed that 71.5% of household sodium intake was in the form of table salt (71.5%) or salt-based condiments (4.7%).19 Limitations also include the absence of 24-hour urine collection, which would help to substantiate the accuracy of these data. The high sodium intake assessed based on the National Dietary Survey might still be underestimated. In addition, we only analyzed intake data from the first day of food record, which might not adequately represent typical dietary consumption. However, 1-day food records have been previously considered sufficient to estimate food contribution to sodium intake, when not individual but population means of food group consumption are compared.20 The option to use only data from the first day of food records in the present study was justified by missing data (3.2% of individuals) in the second day, because missing values in complex surveys can potentially bias the estimates.21 In addition, if two food records were used, dietary intake estimates would have to be deattenuated by within-person variability and, consequently, be based on population means instead of individual intakes.22 Data collected on the first day of food records usually provide more accurate estimates than those obtained on subsequent days.23
CONCLUSIONS Our findings indicated that in all age and sex groups, sodium intake was greater than the tolerable upper limit level. Intervention programs aimed at reducing sodium consumption should target reducing the sodium content of foods with a high density of sodium, which are mostly processed foods. Finally, these observations could provide the basis for increasing consumer awareness about the need to modify eating habits.
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Basiotis PP, Welsh SO, Cronin FJ, Kelsay JL, Mertz W. Number of days of food intake records required to estimate individual and group nutrient intakes with defined confidence. J Nutr. 1987;117(9): 1638-1641. http://jn.nutrition.org/content/117/9/1638.long. Accessed February 1, 2013.
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RESEARCH 21.
Gorrell, P. Survey analysis: Options for missing data. http://www.nesug. org/Proceedings/nesug09/sa/sa03.pdf. Accessed January 08, 2013.
22.
Beaton GH, Milner J, McGuire V, Feather TE, Little JA. Source of variance in 24-hour dietary recall data: Implications for nutrition study design and interpretation. Carbohydrate sources, vitamins, and minerals. Am J Clin Nutr. 1983;37(6): 986-995.
23.
Subar AF, Kipnis V, Troiano RP, et al. Using intake biomarkers to evaluate the extent of dietary misreporting in a large sample of adults: The OPEN study. Am J Epidemiol. 2003;158(1):1-13.
AUTHOR INFORMATION A. de Moura Souza is a postdoctoral researcher and R. Sichieri is a full professor, Department of Epidemiology, Institute of Social Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil. I. Nogueira Bezerra is an assistant professor, University of Fortaleza (UNIFOR), Fortaleza, Brazil. R. Alves Pereira is an associate professor, Department of Nutrition, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil. K. E. Peterson is a professor and director, Human Nutrition Program, School of Public Health, University of Michigan, Ann Arbor, and adjunct professor, Department of Nutrition, Harvard School of Public Health, Boston, MA. Address correspondence to: Amanda de Moura Souza, PhD, MPH, Department of Epidemiology, Institute of Social Medicine, State University of Rio de Janeiro, Rua São Francisco Xavier, 524, 7 andar, Bloco E, Cep 20550-900, Rio de Janeiro, RJ, Brazil. E-mail: [email protected]
STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT The survey was funding by the Brazilian Ministry of Health. A. de Moura Souza received a fellowship from the Brazilian Federal Agency for the Improvement of Higher Education (CAPES), process n.454411-0.
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Dietary Sources of Sodium Intake in Brazil in 2008-2009 Amanda de Moura Souza, PhD, MPH; Ilana Nogueira Bezerra, PhD, MPH; Rosangela Alves Pereira, PhD, MPH; Karen Eileen Peterson, ScD; Rosely Sichieri, PhD, MD ARTICLE INFORMATION
ABSTRACT
Article history:
Information on the main dietary sources of sodium is essential for developing public health strategies to reduce sodium intake. This study aimed to describe sodium intake according to sex, age, and income and identify the main dietary sources of sodium in Brazil. In total, 34,003 subjects aged 10 years and older participated in the first Brazilian National Dietary Survey, conducted in 2008-2009. Food was classified according to the sodium profile into 31 groups based on a 1-day food record. The daily per capita intake of sodium (mg/day) and sodium density (mg/100 g) were estimated for each food group and stratified by sex, age, and per capita income quartile. The average daily intake of sodium was 3,190 mg/day. The sodium density of the diet increased with age and income (P<0.05). Food groups with the highest densities for both sexes and across all income quartiles included salty preserved meats (997 mg/100 g), processed meats (974 mg/100 g), cheeses (883 mg/100 g), crackers (832 mg/100 g), sandwiches (800 mg/100 g), pizza (729 mg/100 g), and breads (646 mg/100 g), as well as oils, spreads, sauces, and condiments (804 mg/100 g). Altogether, these food groups contributed to 811 mg/day of sodium, which is more than half of the recommended daily sodium intake. Mean sodium intake in Brazil exceeded the tolerable upper intake level of 2,300 mg/day. Processed food contributed to half of the recommended intake and should be targeted by future public health policies aiming at reducing total sodium intake.
Accepted 22 April 2013 Available online 3 July 2013
Keywords: Sodium intake Dietary survey Brazil Copyright ª 2013 by the Academy of Nutrition and Dietetics. 2212-2672/$36.00 http://dx.doi.org/10.1016/j.jand.2013.04.023
J Acad Nutr Diet. 2013;113:1359-1365.
D
URING THE PAST SEVERAL DECADES, SODIUM intake in median and high-income countries has been excessive, varying from 3,600 to 4,800 mg/ day.1 These values exceed the tolerable upper intake levels of 2,200 mg/day (for individuals aged 9 to 13 years) and 2,300 mg/day (for individuals aged 13 years and older) of sodium recommended by the US Dietary Reference Intakes.2 A high intake of sodium is a public health concern because excessive consumption is associated with development of high blood pressure.3 For example, a population-based study conducted in Canada estimated that 30% of hypertension is related to high sodium consumption.4 In Brazil, approximately 23% of adults were medically diagnosed with hypertension (blood pressure 140/90 mm Hg) in 20105 and, in 2007, 3.7% of all deaths were attributed to high blood pressure.6 The prevalence of excessive sodium intake in the first Brazilian National Dietary Survey ranged from 71% in girls (14 to 18 years of age) to 89% in adult men (19 to 59 years of age).7 Few countries have collected nationally representative data on the dietary sources of sodium, which is fundamental for developing policies to reduce salt intake.8 Such information could help educate people on the importance of appropriate sodium consumption, as well as help develop policies for reducing sodium levels in specific food products and indicating sodium content in food product labeling. ª 2013 by the Academy of Nutrition and Dietetics.
This study aimed to describe sodium intake according to sex, age, and income, and identify the main dietary sources of sodium in Brazil.
METHODS This study analyzes data obtained in the first nationwide dietary survey conducted in Brazil by the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatistica) along with the 2008-2009 Household Budget Survey.9 Food consumption of a representative sample of the Brazilian population 10 years of age or older (subsampled from the households investigated in the Household Budget Survey) was ascertained by two nonconsecutive food diaries obtained on predetermined days spanning 1 week.
Subjects The households in the main sample were selected by a twostage complex cluster sampling design, with the census tracts as primary sampling units and households as secondary sampling units. Primary sample units were selected by systematic sampling with proportional probability to the number of households based on the 2000 Brazilian Demographic Census. Primary sample units were stratified by socioeconomic and geographic strata, and JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
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RESEARCH Food groups
Description
Beans and legumes
Beans, pea, soy meat, and other legumes
Breads
White and whole-wheat breads and bread toasts
Breakfast cereals
Ready-to-eat and cooked cereals
Cakes and cookies
All cakes, sweets cookies, and filling cookies
Cheeses
Mozzarella, cottage, cheddar, and others
Corn/corn dishes
Corn, corn meals, corn flour, polenta, and other corn dishes
Crackers
Crackers and chips (potato/corn)
Deep-fried and baked snacks
Salty pastries, chicken/meat/cheese patties, deep fried snacks, and others
Desserts and sugar
Milk and fruit desserts, pies, sweet pastries, candies, honey, sugar
Eggs
Egg and egg dishes
Fish and shellfish
Fish/shellfish and mixtures with grains and/or vegetables
Fruits
All fruits and salad fruits (does not include fruit juices)
Green leaf vegetables
Lettuce, spinach, rucola, and others
Meat/meat dishes
Meat and mixtures with grains and/or vegetables
Milk and dairy
Fluid milk, yogurt, chocolate milk (does not include milk dessert)
Nuts
Peanuts, cashew nuts, almonds, and others
Oils, spreads, sauces, and condiments
Vegetable oils, olive oil, butter, margarine, mayonnaise, and others
Other beverages
Fruit juices, fruit drinks, coffee, tea, and alcoholic beverages
Other tubers
Manioc, yam, and tuber products
Other vegetables
Tomato, pumpkin, carrots, squash, and others
Pasta/pasta dishes
Spaghetti, ravioli, lasagna
Pizza
Pizzas and calzones
Pork/pork dishes
Pork and mixtures with grains and/or vegetables
Potato
All potato items other than potato chips
Poultry/poultry dishes
Poultry and mixtures with grains and/or vegetables
Processed meats
Ham, luncheon meats, frankfurters
Rice/rice dishes
White rice, rice with legumes, sushi, and other rice dishes
Salty preserved meats/fish
Meats preserved with high amount of salt and salty codfish
Sandwiches
Hamburgers, cheeseburgers, egg/cheese/ham sandwiches
Soft drinks
Soft drinks
Soups
Soups and broths
Figure. Food groups in 2008-2009 Brazilian National Dietary Survey.
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RESEARCH households were selected by simple random sampling. Twenty-five percent of the Household Budget Survey participants (approximately 14,000 households) were randomly selected. The survey response rate was 81%. The National Dietary Survey was designed to collect information on the food consumption of all family members older than 10 years of age (N¼34,003). The research protocol was approved by the Committee of Ethics in Research of the Institute of Social Medicine (CAAE 0011.0.259.000-11).
Dietary Intake In this analysis, sodium intake was estimated based on food and beverage consumption data obtained in the first of the two nonconsecutive food records. Participants described all food and beverages consumed, in addition to the following: the cooking method (eg, raw, cooked, fried, with tomato sauce) used for specific items (meats, poultry, fish, and vegetables); the amount of food consumed; and the time and place where food and beverages were consumed. The participants received a manual with instructions for completing the survey, as well as photographs of household utensils and containers (tableware, cans, and bottles) to assist in the estimation of food portions. Food records were reviewed in personal interviews conducted in the households by trained interviewers who probed the participants on usually forgotten foods and sought to clarify doubts and incomplete information in the records. In addition, for food records with less than five items or presenting periods longer than 3 hours without any reported food intake, the respondents were asked to either confirm the information or to provide data on consumed foods and/or beverages. Data entry was performed using specific software developed by the Brazilian Institute of Geography and Statistics. Partial analyses were performed during data collection to check data quality. The 2-day register was tested against doubly labeled water in a study performed among adults from Duque de Caxias, Rio de Janeiro. The estimation of energy expenditure by doubly labeled water indicated an underestimation of 17% of energy intake.9
The sodium content in foods and beverages was estimated using the Nutrition Data System for Research software version 2008,10 the Brazilian Food Composition Table,11 and Brazilian studies on regional foods.12 In order to identify the major food sources of sodium, the 1,971 items (food and beverages) reported in the survey were classified into 31 food groups based on sodium profile (Figure).
Statistical Analysis Trends in sodium intake and sodium density across income levels and age strata were analyzed using linear regression models. Sodium intake and sodium density variables were log-transformed in order to approximate a normal distribution. Monthly per capita household income was calculated as the total household income divided by the number of household members and categorized into quartiles: US $124; >US $124, and US $240; >US $240, and US $458; and >US $458 (per capita, per month). Differences between food groups mean sodium density (mg/100 g) across age, sex, and income groups were determined based on overlapping confidence intervals for mean values. All statistical analyses were performed using survey procedures from the Statistical Analysis System (version 9.3, 2011, SAS Institute Inc) and accounted for weighting and the multi-stage sampling design.
RESULTS AND DISCUSSION This is the first study to describe the main contributors to sodium intake in the Brazilian diet using data from a nationwide dietary survey. Mean daily intake of sodium was estimated at 3,190 mg/day and exceeded the tolerable upper intake level in strata. Sodium consumption was higher among male subjects and decreased with age among female subjects, but, for male subjects, an inverted V-shaped association between sodium consumption and age was observed (Table 1). No difference in intake was observed with income among women, whereas an inverted J-shaped association between intake and income was observed for men (Table 1).
Table 1. Sodium daily intake (mg/day) and standard error according to age group and income level by sex among Brazilian National Dietary Survey respondents, 2008-2009 Age Group Elderly
P value
3,66628.0
3,22946.9
<0.01a
2,82820.8
2,64448.0
<0.01b
Total
Adolescent
Adults
Males
3,58024.7
3,52349.5
Females
2,82618.2
2,94937.3
1st
2nd
Males
3,42544.8
3,65644.1
3,69947.3
3,56354.6
<0.01a
Females
2,80430.5
2,83234.1
2,85535.5
2,82540.9
0.40b
mg/daystandard error
Income Quartile 3rd
4th
mg/daystandard error
a
Quadratic association. Linear trend based on regression analysis.
b
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Men 10-19 y Food groups
%
Beans and legumes
15.2
Breads
11.0
mg/100 g
%
225.3
15.6
226.0
15.0
225.6
12.6
646.6
10.6
647.6a
10.3
647.7
11.2
a
abc
0.0
322.5
2.1
216.3
Cheeses
0.8
740.9bc 259.9
a a
Crackers
2.6
822.8
Deep-fried and baked snacks
1.4
380.8
Desserts and sugar
0.7
Eggs
10-19 y
mg/100 g
Cakes and cookies
1.8
60D y
%
Breakfast cereals
Corn/corn dishes
Women
20-59 y
70.0c abc
mg/100 g
%
20-59 y
mg/100 g
60D y
%
mg/100 g
%
mg/100 g
224.5
12.8
225.7
12.3
225.2
646.9
11.4
643.2a
11.1
645.2
ad
ae
0.0
100.7
0.0
113.7
0.1
255.8
0.0
203.4
0.1
105.8
0.9
159.9
0.9
162.6
2.3
208.2
1.2
164.6
1.0
152.0
1.8
862.9f
3.1
1,073.5
0.9
700.4dg
2.4
884.1
3.6
992.3
1.7
266.0
1.8
260.7
1.8
275.2a
1.7
267.7
1.7
260.4
a
1.5
841.7
1.4
853.5
2.9
787.5
2.0
842.6
2.7
849.5
1.0
360.7
0.8
412.7
1.6
341.6
1.2
371.6
0.9
378.5
0.4
68.6f
0.3
53.9
0.9
68.2
0.6
70.7
0.4
59.5
1.2
316.9
1.1
310.7a
1.2
314.1ad
1.0
310.1e
0.9
296.0a
1.3
330.1
Fish and shellfish
3.3
439.4
3.4
437.6
3.5
440.1
2.8
440.3
3.4
439.2
3.9
439.3
Fruits
0.0
1.4
0.0
1.2
0.0
1.3
0.0
1.3
0.0
1.3
0.1
1.3
Green vegetables
0.2
61.9
0.5
69.7
0.6
76.6
0.3
59.7
0.7
70.4
0.8
74.1
Meat/meat dishes
8.2
409.0
9.3
403.0
8.8
406.7
8.1
412.9
8.7
407.3
7.6
411.0
Milk and dairy
2.5
44.1
1.7
38.3
3.5
53.8
3.2
48.5
2.6
41.2
4.3
49.8
Nuts
0.0
42.4c
0.0
67.3a
0.0
241.4f
0.0
101.4g
0.0
205.6a
0.0
88.0
Oils, spreads, sauces, and condiments
1.8
802.2
1.8
806.2
1.6
815.5
1.9
828.2
1.9
802.3
1.8
763.9
Other beverages
0.9
4.6
1.3
4.3
1.2
5.4
1.2
5.2
1.1
4.5
1.2
4.0
ab
f
ad
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Other cereals and tubers
0.3
155.6
0.7
193.7
1.0
166.7
0.5
210.2
0.7
200.6
1.4
182.6
Other vegetables
0.4
112.6
0.5
133.1
0.6
155.9
0.5
160.6
0.5
133.3e
0.4
172.6
Pasta/pasta dishes
2.9
240.1
3.1
234.4
2.3
240.8
3.3
239.3
3.2
237.1
2.1
237.4
Pizza
0.6
729.5abc
1.3
734.2f
0.1
752.4a
1.5
718.3a
1.3
727.4
0.3
719.4a
Pork/pork dishes
0.5
239.9
0.8
258.1
0.7
270.2
0.6
247.4
0.7
263.2
0.7
271.8
Potato
1.2
312.2c
1.6
303.5
1.6
285.4
1.8
308.4d
1.8
302.2
1.6
285.7
Poultry/poultry dishes
4.5
416.0
4.9
415.8
4.6
419.1
4.9
417.5
5.2
416.7
4.7
417.8
Processed meats
2.9
961.7
2.9
975.2
2.9
1,044.9
2.7
989.7
2.3
959.0
1.8
978.0
Rice/rice dishes
20.8
381.2
22.0
382.5
20.3
384.0
19.0
381.9
19.4
382.2
18.9
383.2
2.3
1,262.0
1.7
954.2
1.8
724.5a
1.7
1,153.5
1.8
979.6
Salty preserved meats
1.5 976.8a (continued on next page)
RESEARCH
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Table 2. Percentage of total sodium intake (%) and sodium density (mg/100 g) provided by food groups according to sex and age among Brazilian National Dietary Survey respondents, 2008-2009
353.9a
7.0 0.1
10.7
784.3 1.5
7.2
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P values <0.05 comparisons for density: a In each age and sex groups. b Adolescent and adult males. c Adolescent and elderly males. d Adolescent and elderly females. e Adult and elderly females. f Adult and elderly males. g Adolescent and adult females.
5.8 0.2
6.4
349.3
0.3
8.3
6.1 5.7
348.9 4.4
0.2
5.1 Soups
5.9 0.2 Soft drinks
348.9
0.1
340.6a
6.4
341.7
e
798.2 3.0 743.2a 3.9 835.3 1.8 815.1 3.2 811.1a 4.2 Sandwiches
mg/100 g
60D y
% 20-59 y
mg/100 g mg/100 g mg/100 g mg/100 g mg/100 g % Food groups
10-19 y
%
20-59 y
%
60D y
%
10-19 y
%
Women Men
Table 2. Percentage of total sodium intake (%) and sodium density (mg/100 g) provided by food groups according to sex and age among Brazilian National Dietary Survey respondents, 2008-2009 (continued)
RESEARCH Similar results were observed in the United States (3,330 mg/day) 13 and Canada (3,098 mg/day).14 Mean daily intake of sodium was higher among American men than among American women and sodium consumption was above the tolerable upper intake level for all individuals, except for children aged 2 to 5 years.13 In the US population, the differences in sodium intake across all age and sex groups were explained by differences in energy consumption,13 and in Brazil, sodium intake among men adjusted for energy intake remained higher than that among women. After adjusting for energy intake, sodium consumption was positively associated with age and inversely associated with income level for both sexes. These associations could be explained by differences in food consumption profile across age and income groups, for example, the positive association between age and sodium indicate that elderly individuals choose foods with higher sodium content. The highest percentage of sodium intake for all age and sex groups was attributed to rice/rice dishes, beans, and breads (Table 2). These food groups are considered important sources of sodium because of their frequent consumption. Based on the first day of food record, 86% of the participants reported the consumption of rice and 74% of them reported beans intake. However, traditional Brazilian foods, such as rice and beans, have low sodium density (382 mg/100 g and 226 mg/100 g, respectively). Foods with sodium densities >600 mg/100 g included salty preserved meats (997 mg/100 g), processed meats (974 mg/ 100 g), cheeses (883 mg/100 g), crackers (832 mg/100 g), sandwiches (800 mg/100 g), pizza (729 mg/100 g), and breads (646 mg/100 g), as well as oils, spreads, sauces, and condiments (804 mg/100 g). Altogether, these eight food groups contributed to 25% (811 mg/day) of the average daily sodium intake, amounting to nearly 40% of the tolerable upper intake level (2,300 mg/day) for adults (Table 2). More specifically, they contributed to 26%, 25%, and 23% of total sodium consumption among adolescent, adult, and elderly male subjects, respectively, and 27%, 26%, and 25% among adolescent, adult, and elderly female subjects, respectively (Table 2). Except for rice and beans, the contributors to sodium intake are similar to the findings from surveys in developed countries. Population-based study from Canada (The Canadian Community Health Survey 2.2, using one 24-hour recall, found that breads and processed meats were the main dietary source of sodium across all age groups (1 to 8 years, 9 to 18 years, and 19 years or older); however, vegetables (excluding canned or pickled vegetables and potatoes) were the third highest contributing food source to sodium intake among female subjects aged 19 years or older.14 In the United States, the 2007-2008 National Health and Nutrition Examination Survey, based on one 24-hour recall, found that breads, salad dressings, cheeses, and soups were major dietary sources of sodium.13 Among British adults aged 19 to 64 years, breads, fats, cheeses, sauces, chips, and meat products were the main contributors.15 No other Latin American countries have published reports on the main food sources of sodium using national representative samples. The 2005 National Survey on Nutrition and Health in Argentina, which investigated salt consumption among children younger than 5 years of age and female subjects aged 10 to 49 years, reported an average salt intake of 3.1 g/day from processed food consumption among female JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
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RESEARCH subjects aged 10 to 49 years16 more than half of the tolerable upper limit of intake level. Our analysis stratified by income showed a decline in sodium intake from sources such as eggs, meat/meat dishes, salty preserved meats, as well as oils, spreads, sauces, and condiments in the highest income quartile. For items such as breakfast cereals and salty preserved meats, density is reduced by half. Reducing salt intake is one of the World Health Organization strategies to prevent noncommunicable diseases.17 These strategies include monitoring and evaluating salt consumption amounts, identifying dietary sources of salt, reducing the amount of salt added to food, and introducing programs to increase consumer knowledge and healthy behavior that lead to reduced dietary salt intake.17 In Brazil, the Ministry of Health and the Brazilian Association of Food Industry have established a partnership to reduce the sodium content of processed foods.18 These changes are expected to result in 30% reductions in the sodium content of industrialized pasta and 10% in breads and white buns.18 However, because the industry recognizes the importance of regulating sodium intake, changes should be applied, as soon as possible, to processed foods such as processed meats, which constitute the food group with the second highest sodium density. A limitation of this study was that we could not estimate the amount of table salt added to food. Data from the 2002-2003 Brazilian Household Budget Survey showed that 71.5% of household sodium intake was in the form of table salt (71.5%) or salt-based condiments (4.7%).19 Limitations also include the absence of 24-hour urine collection, which would help to substantiate the accuracy of these data. The high sodium intake assessed based on the National Dietary Survey might still be underestimated. In addition, we only analyzed intake data from the first day of food record, which might not adequately represent typical dietary consumption. However, 1-day food records have been previously considered sufficient to estimate food contribution to sodium intake, when not individual but population means of food group consumption are compared.20 The option to use only data from the first day of food records in the present study was justified by missing data (3.2% of individuals) in the second day, because missing values in complex surveys can potentially bias the estimates.21 In addition, if two food records were used, dietary intake estimates would have to be deattenuated by within-person variability and, consequently, be based on population means instead of individual intakes.22 Data collected on the first day of food records usually provide more accurate estimates than those obtained on subsequent days.23
CONCLUSIONS Our findings indicated that in all age and sex groups, sodium intake was greater than the tolerable upper limit level. Intervention programs aimed at reducing sodium consumption should target reducing the sodium content of foods with a high density of sodium, which are mostly processed foods. Finally, these observations could provide the basis for increasing consumer awareness about the need to modify eating habits.
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Núcleo de Estudos e Pesquisas em Alimentação. Tabela brasileira de composição de alimentos (TACO). http://www.unicamp.br/nepa/ taco/contar/taco_versao2.pdf. Accessed July 1, 2011.
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AUTHOR INFORMATION A. de Moura Souza is a postdoctoral researcher and R. Sichieri is a full professor, Department of Epidemiology, Institute of Social Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil. I. Nogueira Bezerra is an assistant professor, University of Fortaleza (UNIFOR), Fortaleza, Brazil. R. Alves Pereira is an associate professor, Department of Nutrition, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil. K. E. Peterson is a professor and director, Human Nutrition Program, School of Public Health, University of Michigan, Ann Arbor, and adjunct professor, Department of Nutrition, Harvard School of Public Health, Boston, MA. Address correspondence to: Amanda de Moura Souza, PhD, MPH, Department of Epidemiology, Institute of Social Medicine, State University of Rio de Janeiro, Rua São Francisco Xavier, 524, 7 andar, Bloco E, Cep 20550-900, Rio de Janeiro, RJ, Brazil. E-mail: [email protected]
STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT The survey was funding by the Brazilian Ministry of Health. A. de Moura Souza received a fellowship from the Brazilian Federal Agency for the Improvement of Higher Education (CAPES), process n.454411-0.
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