Factors associated with the whole foods consumption by adults and elderly

Objectives: Evaluate associated factors to the consumption of whole foods by adults and elderly people. Methods: Cross-sectional study carried out in a municipality in the southwest of Paraná, in which an interview was conducted, comprising 41 objective questions, in adults and the elderly. The factors associated with the consumption of whole foods were evaluated using logistic regression models. Results: The sample consisted of 388 people, predominantly of women, white people, resident in the urban area, with more than 11 years of schooling belonging to socioeconomic class B2-C1. More than a half of the participants reported consuming whole foods (54.6%), however, 21.23% consumed them of irregular form. It was noticed that the female people (Odds Ratio: 2.24; CI 95%=1.38-3.65), physically actives (Odds Ratio: 3.33; CI 95%=1.89–5.87), and that had a greater knowledge about whole foods (Odds Ratio: 1.66; CI 95%=1.01–2.74) had greater chances of consuming them. Related to the regular consumption of these foods, overweight people (Odds Ratio: 0.45; CI 95%=0.21–0.96) presented less chances of ingestion, and the mean of communication and the health professional (Odds Ratio: 2.78; CI 95%=1.07–7.18) presented positive influence in regular consumption of whole foods. Conclusions: There is a need to increase the consumption of whole foods in specific audiences, such as men, sedentary, lower economic class, individuals who do not have knowledge about whole foods and those who are overweight. Ratio: 2,24; 95% = 1,38-3,65), (Odds Ratio: 3,33; 95% = 1,89-5,87) (Odds Ratio: 1,66; IC 95% = 1.01-2.74) alimentos, (Odds Ratio: 0,45; IC 95% = 0,21-0,96) probabilidades los medios los profesionales de la salud (Odds Ratio: 2,78; IC 95% = 1,07-7,18) influencia positiva el consumo regular de alimentos integrales.


Introduction
Whole grain present the composition nearest of the original, and it is composed by three parts: bran, endosperm and germ (Whole Grain Council, 2017). The bran contains vitamins, minerals and fibers, presenting the function of protect the germ and the endosperm from environmental damages. The endosperm contains carbohydrates, proteins and small micronutrients amounts, offering energy to the plant. Finally, the germ contains essentials components, as micronutrients, lipids and proteins. It also contains the embryo, which is the responsible for originate a new plant (Whole Grain Council, 2017; Zhang & Hamaker, 2017).
The whole foods consumption is related to the decrease in the mortality risk from several diseases, such as cardiovascular diseases, Diabetes Mellitus type 2, cancer, respiratory diseases, among others pathologies (Aune et al., 2016;Huang et al., 2015), as well as all-cause mortality (Chen et al., 2016;Zhang et al., 2018), demonstrating the importance of its regular eating. Meta-analysis data (Chen et al., 2016) demonstrated significant associations related to increase intake of whole grains (50 g day -1 ) and reduced mortality by any cause (Relative Risk: 0.78), cardiovascular disease (DCV) (Relative Risk: 0.70). Thus, the importance of the current recommendations to increase the consumption of whole grains, improving the population health stands out.
Despite the benefits arising from the whole foods consumption and the increased demand of it in the supermarket, the Brazilian population and different parts of the world do not reach the current consumption recommendations (Albertson et al., 2016;Guiné et al., 2016;Ross et al., 2017).
Investigations on the determining factors for the consumption of whole foods are scarce. This information would be important to outline public health strategies that aim to stimulate its consumption. In addition, the standardization of definition and labeling of whole food by food industries and regulatory agencies could increase the its consumption, as people may have various worries while purchasing it, due to the labels/packaging that are not clearly arranged, making it difficult for consumers to understand.
In view of the above, this study aimed to assess the factors associated with the whole foods consumption by adults and the elderly.

Methodology
This is a quantitative, descriptive research with data collection in the field and transversal temporality. The research participants were randomly approached in the city of Francisco Beltrão -PR during the months of November 2017 to January 2018, in places with wide people circulation. 397 people were interviewed, a sample defined based on the 2010 demographic census, taking into consideration the total population of the city 78,943 inhabitants (Instituto Brasileiro de Geografia e Estatística, 2010). The inclusion criteria in the research were: being over 20 years of age and residents in the urban or rural area of the municipality.
For data collection, a questionnaire structured by the authors based on the literature (Pimentel & Simões, 2012;Bendino, Popolim & Oliveira, 2012) was applied, consisting of 41 objective questions, divided into 2 dimensions: one that included the characterization of the participants in relation to physical activity, self-reported sociodemographic, clinical, weight and height data and another including questions about knowledge and consumption characteristics of whole foods. If the individual indicated that they consumed whole foods, the interview was conducted in full, including questions about the frequency of consumption. The frequency of consumption in the last 6 months was asked in a semi-quantitative way for 5 foods (bread, pasta, biscuit, rice and whole grains) with 7 answer options, ranging from "never" to "2 or more times a day". If the participant reported not consuming whole foods, the interview ended in question 27, which investigated the reasons for not consuming this type of food.
The socioeconomic profile was defined through the questionnaire of Brazilian Association of Research Companies (2014). Two trained researchers collected the data through a face-to-face interview. An experimental test was realized with 10 participants, to identify possible difficulties in understanding the questions and whether answers contemplated the research objectives.
This research was submitted and approved by the Committee of Moral on Research with human beings of Federal University of Fronteira Sul, CAAE: 77089417.0.0000.5564. For its performance, the participants signed the Term of Free Approval and Clarified (TCLE).
From the data of weight and height was calculated the Body Mass Index (weight/height²) that was classified according to World Health Organization (WHO) (1995) for adults and Lipschitz (1994) for elderly people. The level of physical activity of the participants was also classified according to WHO (2010).
The whole foods consumption was classified as regular once the participants reported consuming any type of whole food 5 or more times a week, considering an usual portion, in the last 6 months. Data were analyzed using the statistical program Stata version 13.0, using the "Pearson`s qui square! to evaluate the differences in proportions between variables, considering p <0.05. Univariate and Multivariate Logistic Regression was performed with a 95% confidence interval to assess the associations between the outcomes: consumption or not of whole foods and its regular/irregular consumption and the exposure variables: gender, ethnicity, home situation, age, marital status, occupation, education, social class, nutritional status, physic activity, intestine habits, pathologies, among others.

Results
From 397 individuals who answered the questionnaire, 9 were excluded due to food intolerances and/or intestine surgery, totaling the sample studied in 388 participants.
The characteristics of the sample studied are exposed in Table 1. Most of the sample was female, white, residents of the urban area, with more than 11 years of schooling and belonging to socioeconomic class B2-C1. Regarding the age of the studied population, young adults were most participants, followed by middle-aged individuals. Table 1 also displays that the whole foods consumption was reported by more than half of the participants (54.6%), with significantly higher percentages of consumption among female (64.3%), white ethnicity (57.8%), > 11 years of study (64.4%), social class A-B1 (63.1%) and physically active people (69.4%.). Regarding the participants' knowledge about whole foods, it was noted that those who reported consuming whole foods were those who significantly more mentioned knowing what whole foods are (63.2%), and Research, Society andDevelopment, v. 10, n. 12, e84101219843, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i12.19843 4 the individuals who reported not consuming whole foods were those who significantly more mentioned did not know about its composition (70.8%).    Research, Society and Development, v. 10, n. 12, e84101219843, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10. 33448/rsd-v10i12.19843 8 With regard to the reasons why individuals use whole products, it was observed in the present study that the influence of the media/indication by a doctor and/or nutritionist had greater chances (Odds Ratio: 2.78) of regular consumption compared to those who consume only through habit or personal taste (Odds Ratio: 0.32).

Discussion
In this study developed in the city of Francisco Beltrão, it was found that 54.6% of the participants mentioned consuming whole food; however, 1/5 of them (21.2%) mentioned irregular frequency consumption. We also found a significant association between being female, physically active, and to have knowledge about whole foods with higher chance of consumption of these foods. Regarding the regular consumption of whole foods we observed that is inversed associated to overweight and positively associated to the influence of the media or because indication of a professional health.
Previous studies have also found low consumption frequency of whole foods. In Malaysia, a study with adult university students found that 51% reported these foods consumption in the last 3 months, with only 13% having daily consumption (Subramanian et al., 2019). In Portugal, an assessment of the attitudes of 382 adults towards dietary fibers found that the frequency of whole grains consumption by the participants was low, being once every two days of the week (Guiné et al., 2016). Mann et al. (2015) suggested that the increase of whole grains consumption must be encouraged, once the small portions consumption can cause an improvement in the diet, such as greater intake of fibers, magnesium and iron and less intake of sodium, therefore, improvement in the health of individuals. Parker et al. (2013) noticed that a consumption of more than two portions of whole grains/day by women between 50 and 79 years resulted in a 43% decrease in the risk of incident diabetes, when compared to women who did not have this daily consumption.
Attitudes related to the whole grains consumption are positively correlated with individuals' knowledge about it (Koo et al., 2018). Data similar to those found in this study were found in the study of Guiné et al. (2016) in which it was identified that female gender (Mean: 3.63 ± 3.58 meals/week) and people with higher education (Mean±DP: 3.32±3.47 meals/week) presented higher consumption of meals containing whole foods in the week, in comparison to the male gender (Mean±DP: 2.30±2.87 meals/week) and individuals who had less education (Mean±DP: 2.26±2.86 meals/week).
Similar result was noticed by Parker et al. (2013) that evaluated the whole grains consumption by women and its association with type 2 diabetes mellitus. The authors identified that women who presented a higher whole grains consumption (>2 portions/day) were more active in relation to physical exercises (16.5 hours/week) compared to 11 hours of physical activity/week for those who did not consume any portion of whole foods. They also presented higher education (university degree or higher) and were less likely to be current smokers, compared to those who did not consume any portion of whole grain on the day. Another study (Huang et al., 2015) also found that the levels of physical activity considered moderate and vigorous were higher in individuals who presented higher whole grains consumption in comparison to those who obtained lower consumption. Vaidean et al. (2017) performed a study with middle-aged adults (between 45 and 64 years old) from southeastern Poland on the frequency of whole grains consumption appropriate and the levels of serum lipids associated with the intake of statin. The authors noticed, among statin users and non-statin users, the association between appropriate whole grains consumption and several variables, as being female, having higher education, living in an urban area, being more physically active, among others. The authors also noticed that rural, males and individuals with less education presented lower whole grains consumption (Vaidean et al., 2015). Although not statistically significant, in the present study, individuals who lived in the rural area also presented lower whole products consumption compared to residents in the urban area.
A study carried out in the United States of America (USA) on the consumption of fibers and whole grains in all ages found low total consumption of both, not reaching the current recommendations (Mc Gill, Fulgoni & Devareddy, 2015). The average fibers consumption of adults was 16.1±0.2 g/day, whereas the average whole grains consumption by adults was 17.29 ±0.56 g/day and for adults aged >51 years, was 24.38 ± 0.56 g/day.
As noticed, individuals who presented greater knowledge about whole foods, consequently presented higher chance of consuming it. A study that corroborates with this finding was developed by Koo et al. (2018), who observed positive and meaningful correlation between the students' knowledge about whole grains with attitudes (r = 0.337; p <0.01) and practices (r = 0.190; p <0.01) regarding to its consumption. An assessment of the Croatian population over the age of 18 years found a weak association between the consumption of foods rich in fiber and the knowledge about it (Ljubicic et al., 2017). Among the different barriers to the whole foods consumption, we can mention the inability to identify whole foods (Barret, Foster & Beck, 2020).
The research developed by Koo et al. (2018), in which the authors evaluated the knowledge, attitudes and students practices in relation to whole grains, identified that eutrophic individuals had practices related to higher whole grains consumption (score:29), in relation to the punctuation obtained through a questionnaire, than by obese or overweight people (score: 27.25), being these data similar to the present study.
The variable that lost its significance after adjusting the model was the question about the items that the individuals observed to decide which whole food buy, despite being non-significant at the 5% confidence level (0.119), presented interesting data, being that individuals who observed the label information are more likely to have regular whole foods consumption compared to those who do not observe any item. Christoph et al. (2018) noticed that the use of nutritional label information by young adults (25 to 36 years old) in Minnesota, was associated with higher intake of food considered healthy, data similar to the present study.
In the study developed by Koo et al. (2018) it was observed that although the students reported not liking whole grains, 39.3% still consumed it, which differs from the data found in this research, since the people who signaled that they did not like whole grains, did not consumed.
Aversion to the organoleptic properties (taste, texture, appearance and smell) of whole foods is one of the main difficulties for increasing the whole grains consumption, which is associated with the price of these foods, greater time for preparation and cooking (Barret, Foster & Beck, 2020). The issue of habit as a barrier to the consumption of these foods was also found in the literature, as well as family preference and availability (Neo & Brownlee, 2017).
It was noted in the study that the usual question was the most prevalent among the reasons for not consuming whole foods. Therefore, strategies must be used to change this scenario, in order to obtain increased consumption of these foods. A strategy that could be listed in view of the results found would be greater dissemination in the media about whole foods and its numerous benefits. Seal et al. (2016) suggest that to achieve an increase in the consumption of whole grains, it is necessary that health and industry bodies establish a standard to correctly define whole foods, making consumption to be optimized. In Brazil, until early 2021, there was no legislation that established the definition of whole foods, nor that it determined mandatory standards of proportionality of whole grains in foods to be considered whole foods. On April 15, 2021, resolution RDC 493 was published, which provides for the composition and labeling requirements of foods containing cereals for classification and identification as whole and to highlight the presence of whole ingredients. This document established the definition of integral ingredient, which would be that coming from whole cereals or their derivatives, with the typical parts and proportions that occur in intact caryopsis: endosperm, starch, bran and germ. In addition, the legislation defined that for a food containing cereals to be classified as whole, it must contain at least 30% of whole ingredients in its composition; and quantity of whole ingredients greater than quantity of refined ingredients. A period of 12 to 24 months was established, depending on the type of food, for adjustments according to the resolution.
Another alternative that has been studied would be the addition of cereal fibers to refined products, such as resistant starch or processed bran to increase the fiber content without changing the texture or flavor of the food. However, there is a lack of studies comparing the potential effect of this addition to health compared to the effects of eating whole grains (Barret, Foster & Beck, 2020).

Conclusion
There was a low whole food consumption in the studied population, being the factors habit and the food tasty, the principal reasons pointed out for not consuming it. The factor associated with higher chances of consuming whole foods were belonging to the female gender, being physically active, from a higher socioeconomic class, and having greater knowledge about whole foods. Regarding to the regular consumption of these foods, overweight individuals were less likely to consume.
We highlight the necessity for further elucidation of these factors in order to increase the whole foods consumption in specific target audience, as men, sedentary, lower economic class, individuals without knowledge about whole foods and overweight individuals.