Abstract

The study analyzed and compared the types of food sold in the surroundings of 30 private and 26 public elementary schools in the city of Niterói, Rio de Janeiro. Data were collected by audit using a checklist instrument to characterize establishments (formal or informal) and identify the types of food and beverages sold, which were classified by processing level (fresh, processed, and ultraprocessed). Mann-Whitney statistical tests were used to verify the difference in the type of trade outlets d the categories of food sold between schools. The Kruskal-Wallis test was used to verify the difference in the amount of food traded between the categories. The amount of ultraprocessed food in the surroundings of public and private schools was statistically higher (p=0.0001) than the other categories. Some culinary preparations had a high rate of energy contribution from ultraprocessed foods (above 15%). There was no statistically significant difference (p = 0.478) in the categories of food sold between public and private schools. The sale of ultraprocessed products predominates around public and private schools, favoring the exposure of children to an environment that encourages the consumption of these products.

Key words:
School environment; School food; Healthy eating

Introduction

Adequate nutrition in childhood contributes to child growth and development¹1 Carvalho CA, Fonseca PCA, Priore SE, Franceschini SCC, Novaes JF. Consumo alimentar e adequação nutricional em crianças brasileiras: revisão sistemática. Rev Paul Pediatr 2015; 33(2):211-21., a crucial phase for the formation of healthy eating habits and maintenance in adulthood. However, conditioning factors related to the physical and social environment interfere with the children’s food choices, sometimes with adverse consequences for health²2 Caspi CE, Sorensen G, Subramanian SV, Kawachi I. The local food environment and diet: a systematic review. Health Place 2012; 18(5):1172-1187.. In this sense, the standardization of eating practices, expansion of the advertising market, and lifestyle changes have favored the greater access to processed and ultraprocessed foods, affecting the population’s health profile. Most of these foods have a high concentration of sugar, fats and sodium, and a high energy density³3 Toloni MHA, Longo-Silva G, Goulart RMM, Taddei JAAC. Introdução de alimentos industrializados e alimentos de uso tradicional na dieta de crianças de creches públicas no município de São Paulo. Rev Nutr 2011; 24(1):61-70.

4 Teo CRPA, Monteiro CA. Marco legal do Programa Nacional de Alimentação Escolar: uma releitura para alinhar propósitos e práticas na aquisição de alimentos. Rev Nutr 2012; 25(5):657-668.

5 World Health Organization (WHO). Plan of action for the prevention of obesity in children and adolescents. 53rd Directing Council. 66 th session of the regional committee of WHO for the Americas. Washington DC: WHO; 2014.

6 World Health Organization (WHO). Report of the commission on ending childhood obesity. Washington DC: WHO; 2016.^-77 Aquino RC, Philippi ST. Consumo infantil de alimentos industrializados e renda familiar na cidade de São Paulo. Rev Saude Publica 2002; 36(6):655-660..

The food environment can be described as a microenvironment that includes the individuals’ locations, such as home, work, neighborhood, school, whose particularities of access to food (availability, quality, and price) guide their consumption choices. In turn, this environment is related to the food macroenvironments established by policies, food industries, advertising, and marketing companies, among others, that indirectly influence the population’s purchase decision and condition consumption profiles⁸8 Costa BVL, Oliveira CDL, Lopes ACS. Ambiente alimentar de frutas e hortaliças no território do Programa da Academia da Saúde. Cad Saude Publica 2015; 31(Supl. 1):S1-S11.^,99 Swinburn B, Egger G, Raza F. dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental interventions for obesity. Prev Med 1999; 29(6):563-570..

In the case of children, the school is one of the main components of the food environment, where children remain for long periods, thus being considered a favorable space for the development of healthy eating practices¹⁰10 Azeredo CM, Rezende LFM, Canella DS, Claro RM, Peres MFT, Luiz OC, França- Júnior I, Kinra S, Hawkesworth S, Levy RB. Food environments in schools and in the immediate vicinity are associated with unhealthy food consumption among?Brazilian adolescents. Prev Med 2016; 88:73-79.. Studies have shown that students, whether from public or private institutions, are exposed to environments that mostly sell ultraprocessed foods¹⁰10 Azeredo CM, Rezende LFM, Canella DS, Claro RM, Peres MFT, Luiz OC, França- Júnior I, Kinra S, Hawkesworth S, Levy RB. Food environments in schools and in the immediate vicinity are associated with unhealthy food consumption among?Brazilian adolescents. Prev Med 2016; 88:73-79.

11 Leite FHM, Oliveira MA, Cremm EC, Abreu DSC, Maron LR, Martins PA. Availability of processed foods in the perimeter of public schools in urban areas. J Pediatr 2012; 88(4):328-334.

12 Schmitz BAS, Recine E, Cardoso GT, Silva JRM, Amorim NFA, Bernardon R, Rodrigues, MLCF. A escola promovendo hábitos alimentares saudáveis: uma proposta metodológica de capacitação para educadores e donos de cantina escolar. Cad. Saude Publica 2008; 24(Supl. 2):S312-S322.

13 Louzada MLC, Martins APB, Canella DS, Baraldi LG, Levy RB, Claro RM, Moubarac JC, Cannon G, Monteiro CA. Alimentos ultraprocessados e perfil nutricional da dieta no Brasil. Rev Saude Publica 2015; 49:1-11.^-1414 Carmo AS, Assis MM, Cunha CF, Oliveira TRPR, Mendes LL. The food environment of Brazilian public and private schools. Cad Saude Publica 2018; 34(12):e00014918., which can impact health if consumed in excess and frequently.

In Brazil, food in public schools is regulated through the National School Food Program (PNAE), which guarantees the supply of healthy meals and establishes guidelines for Food and Nutrition Education (EAN) in schools.

Some legal provisions for the promotion of healthy eating in schools are in place, such as Interministerial Ordinance n° 1010 of May 8, 2006, which establishes guidelines for the promotion of healthy eating in early childhood, elementary and secondary schools of the public and private networks nationwide¹⁵15 Brasil. Ministério da Saúde (MS). Portaria nº 1.010, de 08 de maio de 2006. Institui as diretrizes para a Promoção da Alimentação Saudável nas Escolas de educação infantil, fundamental e nível médio das redes públicas e privadas, em âmbito nacional. Diário Oficial da União. Poder Executivo, Brasília, 2006; 8 maio., the Manual of healthy school canteens, which aims to help owners transform their canteens into places for the promotion of healthy eating¹⁶16 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Manual das cantinas escolares saudáveis: promovendo a alimentação saudável. Brasília: MS; 2010. 56 p., and Law n° 13.666/2018, of the President of the Republic, which determines the cross-sectional inclusion of the EAN theme in the school curriculum¹⁷17 Brasil. Presidência da República. Lei nº 13.666, de 16 de maio de 2018. Altera a Lei nº 9.394, de 20 de dezembro de 1996 (Lei de Diretrizes e Bases da Educação Nacional), para incluir o tema transversal da educação alimentar e nutricional no currículo escolar. Brasília, 2018; 16 maio.. Some Brazilian states and municipalities have already published legislation to regulate the sale of food in school cafeterias¹⁸18 Gabriel CG, Santos MV, Vasconcelos FAG, Milanez GHG, Hulse SB. Cantinas escolares de Florianópolis: existência e produtos comercializados após a instituição da Lei de Regulamentação. Rev Nutr 2010; 23(2):191-199.^,1919 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Experiências estaduais e municipais de regulamentação da comercialização de alimentos em escolas no Brasil: identificação e sistematização do processo de construção e dispositivos legais adotados. Brasília: MS; 2007.. However, there is still no Federal Law regulating the sale of food in these environments¹¹11 Leite FHM, Oliveira MA, Cremm EC, Abreu DSC, Maron LR, Martins PA. Availability of processed foods in the perimeter of public schools in urban areas. J Pediatr 2012; 88(4):328-334.^,2020 Austin SB, Melly SJ, Sanchez BN, Patel A, Buka S, GortmakerSL.Clustering of fast-food restaurants around schools: a novel application of spatial statistics to the study of food environments. Am J Public Health 2005; 95(9):1575-1581.^,2121 Henriques P, O´Dwyer G, Dias PC, Barbosa RMS, Burlandy L. Políticas de Saúde e de Segurança Alimentar e Nutricional: desafios para o controle da obesidade infantil. Cien Saude Colet 2018; 23(12):4143-4152., and there is no inspection or punitive actions for irregularities.

Despite the existence of legal provisions, it is worth considering that the surroundings of schools are convenient places to sell foods of interest to children (candies, chocolates, and other treats) that can hinder the promotion of healthy eating even in schools where education programs are implemented or in those with healthy eating-oriented canteens²²22 Missbach B, Pachschwöll C, Kuchling D, König J. School food environment: Quality and advertisement frequency of child-oriented packaged products within walking distance of public schools. PrevMed Rep 2017; 6:307-313.. Thus, considering that students already have the autonomy to buy food in canteens and in commercial establishments around schools, which do not always have healthy snack options²³23 Gaethani RS, Ribeiro LC. Produtos Comercializados em Cantinas Escolares do Município de Ribeirão Preto. Rev Bras Prom Saude 2015; 28(4):587-595.^,2424 Neto ARV, Melo LGNS. Fatores de influência no comportamento de compra de alimentos por crianças. Saude Soc 2013; 22(2):441-55. and that few studies explore the analysis of the food environment in the school environment, this study aimed to analyze and compare the types of food sold around public and private schools in the city of Niterói-RJ.

Methods

This is an observational and descriptive research conducted by the Education, Extension, and Research Group on Food and School Health (GEPASE/UFF). This study considered all formal and informal commercial establishments located within a radius of 500 meters from the primary access school’s gate¹¹11 Leite FHM, Oliveira MA, Cremm EC, Abreu DSC, Maron LR, Martins PA. Availability of processed foods in the perimeter of public schools in urban areas. J Pediatr 2012; 88(4):328-334.^,2525 Park S, Choi BY, Wang Y, Colantuoni E, Gittelsohn J. School and neighborhood nutrition environment and their association with students' nutrition behaviors and weight status in Seoul, South Korea. J Adolesc Health 2013; 53(5):655-662. to delimit the food environment of the school’s surroundings.

Initially, a search was made on the Niterói’s Municipal website to select public schools, and a total of 120 municipal school units were found (community daycare centers, early childhood education, elementary education, and youth and adult education). Forty-nine elementary schools were selected, composed of students aged 7-15 years, who already have decision-making power over their food choices²⁶26 Dutra RCA. Consumo alimentar infantil: quando a criança é convertida em sujeito. Soc Estado 2015; 30(2):451-469.. Fourteen schools in risk areas were excluded due to urban violence, which resulted in a final sample of 35 municipal school units.

A search was carried out on “Google Maps” to select private schools and locate the units closest to the municipal schools previously selected, also totaling 35 schools. After this stage, schools whose surroundings did not identify food establishments, formal or informal, were excluded, leaving 30 private schools and 26 public schools.

Data were collected from August 2017 to June 2018, through an audit, which corresponds to the assessment of the food environment by direct observation of the place²⁷27 Glanz K, Sallis JF, Saelens BE, Frank LD. Healthy nutrition environments: concepts and measures. Am J Health Promot 2005; 19(5):330-333.. Information was registered with a checklist instrument elaborated by researchers and pre-tested in the school surroundings of a neighboring municipality, containing two topics: 1) characterization of establishments (formal or informal) and 2) availability and types of food and beverages sold.

Subsequently, the foods sold around public and private schools were classified by processing level (fresh or minimally processed, processed, and ultraprocessed) according to the Food Guide for the Brazilian Population, namely:²⁸28 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para a população brasileira. 2ª ed. Brasília: MS; 2014. 156 p.^,2929 Monteiro CA, Cannon G, Levy RB, Moubarac J-C, Jaime P, Martins AP, Canella D, Louzada ML, Parra D; com Ricardo C, Calixto G, Machado P, Martins C, Martinez E, Baraldi L, Garzillo J, Sattamini I Classificação dos alimentos. Saúde Pública: NOVA A estrela brilha. World Nutrition 2016; 7(1-3):28-40.

Fresh and minimally processed foods: include those that can be consumed without undergoing any modification after leaving nature or those that are subjected to cleaning, removal of inedible parts, portioning, freezing, and other processes that do not add any other substance that alters its original form;

Culinary ingredients: include substances taken from fresh foods that are used as items of culinary preparations, such as oils, vinegar, sauces, salt, and sugar;

Processed foods: include those manufactured with salt or sugar, oil, or other processed ingredients over fresh or minimally processed food;

Ultraprocessed foods: include processed products, usually made with more than five ingredients that provide high palatability and longer duration, where these ingredients used are additives, antioxidants, stabilizers, and preservatives;

Culinary preparations: defined as recipes consisting of natural or processed foods³⁰30 Philippi ST. Nutrição e Técnica Dietética. 3 ed. São Paulo: Manole; 2014. and culinary ingredients²⁸28 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para a população brasileira. 2ª ed. Brasília: MS; 2014. 156 p.. They were characterized by the determination of the per capita number of food/culinary ingredients present in each preparation according to the “Table for assessing food consumption in home measures”³¹31 Pinheiro ABV, Lacerda EMA, Benzecry EH, Gomes MCS, Costa VM. Tabela para avaliação de consumo alimentar em medidas caseiras. 4ª ed. São Paulo: Atheneu; 2004. 78 p..

The number of kilocalories of each food/ingredient was calculated from the characterization of culinary preparations, as per the “Brazilian food composition table”³²32 Universidade Estadual de Campinas. Núcleo de Estudos e Pesquisas em Alimentação. Tabela brasileira de composição de alimentos - TACO. 4ª ed. Campinas: UNICAMP/NEPA; 2011. 161 p.. Finally, the energy contribution rates of each food/ingredient of the culinary preparation according to the classification of the processing level of the food guide²⁸28 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para a população brasileira. 2ª ed. Brasília: MS; 2014. 156 p.^,2929 Monteiro CA, Cannon G, Levy RB, Moubarac J-C, Jaime P, Martins AP, Canella D, Louzada ML, Parra D; com Ricardo C, Calixto G, Machado P, Martins C, Martinez E, Baraldi L, Garzillo J, Sattamini I Classificação dos alimentos. Saúde Pública: NOVA A estrela brilha. World Nutrition 2016; 7(1-3):28-40..

Culinary preparations were classified according to the ingredient contribution rate and categorized as per the predominance of fresh/minimally processed, processed, and ultraprocessed foods). Teo and Monteiro⁴4 Teo CRPA, Monteiro CA. Marco legal do Programa Nacional de Alimentação Escolar: uma releitura para alinhar propósitos e práticas na aquisição de alimentos. Rev Nutr 2012; 25(5):657-668. affirm that the recommended participation of ultraprocessed foods in the diet should not exceed 15% of the total meal energy. In the case of this study, the energy contribution of ultraprocessed foods was limited to 15% of the total energy of the culinary preparation.

Data statistical analysis

The normality distribution of the variables was verified using the Kolmogorov-Smirnov test. Considering that all variables had a non-parametric distribution, the Mann-Whitney test was used to verify the difference in the type of trade between public and private schools, the Kruskal-Wallis test to verify the statistical difference in the amount of food traded among the categories (fresh/minimally processed, processed or ultraprocessed) and the Mann-Whitney test to verify the statistical difference of the different categories of food sold between public and private schools considering the level of significance at 5%. The SPSS (Statistical Package for Social Sciences) program, version 13.0, was used to perform the statistical analysis. Data are presented in median and percentile distribution [P25; P75].

Results

The study identified a total of 285 establishments around the 56 public and private elementary schools, of which 80% were formal establishments (48% around private schools and 32% around public schools, p=0.230), and 20% were informal establishments (8% around private schools and 12% around public schools, p=0.553). As for the characteristic of the existing trade, there was a predominance of snack bars (15% in both surroundings) and restaurants in public and private schools (14% and 15%, respectively) and a smaller number of markets/corner stores and grocery stores, with 5% and 4% in public schools and 7% and 6% in private schools, respectively.

Table 1 shows that the sale of ultraprocessed foods was higher than 65%, regardless of the type of schools, and was statistically higher (p=0.0001) than the other categories. Twenty-five types of ultraprocessed foods were identified, with the highest rate of sweets (candies, chewing gum, chocolates, and chocolates), cookies (salty and sweet), popsicles, processed drinks and soft drinks in both environments.

The high supply of processed cake and ice cream was identified around the private schools and processed popcorn around the public ones. Regarding fresh or minimally processed foods, the highest rates sold were mineral water and fruit juice around private schools and mineral water in the vicinity of public schools. As for processed products, only coconut water was identified in both environments.

There was a more significant offer of culinary preparations composed of processed and ultraprocessed foods in the surroundings of public and private schools. Of the preparations made up of fresh/minimally processed foods, fruit milkshake/smoothie had a higher supply. The most available preparations, composed of processed foods, were salty (fried and roasted) and fruit refreshment. There was a greater variety of preparations composed with a predominance of ultraprocessed foods and the natural and ham and cheese sandwich in a higher number of areas in private schools, and ham and cheese sandwich, and hamburgers in the surroundings of public schools (Table 1).

Some culinary preparations such as hot dogs, natural ham and cheese sandwiches, and salty pastry (fried and roasted) presented a high rate of energy contribution from ultraprocessed foods (above 15%). On the other hand, tapioca, fruit salad, fruit refreshment, and fruit milkshake/smoothie did not show an ultraprocessed energy contribution (Table 2).

The sale of food according to the different categories was not statistically different between public and private schools (p>0.05) (Table 3). However, considering all schools (n=56), the number of ultraprocessed foods sold (18 [12;21]) was statistically higher than the number of fresh/minimally processed foods (2 [1;4]) and processed foods sold (0 [0;1]) (p=0.0001).

Discussion

In this study, there was no significant difference in public and private schools’ surroundings as to the type of food sold. It was shown that both had a significant number of trade outlets that sold, predominantly, foods of low nutritional value, with high levels of critical nutrients and additives in their composition. These foods are known for several attributes, such as, for example, hyperflavor, which compromise satiety and control appetite, favoring involuntary consumption, and increasing the risk of obesity³³33 Instituto de Defesa do Consumidor. Alimentação saudável nas escolas. Guia para municípios. [acessado 2019 maio 15]. Disponível em: http://www.idec.org.br.
http://www.idec.org.br... . Therefore, their sale represents a challenge for the promotion of healthy eating habits and requires the development of public policies that regulate the food supply and promote environments conducive to healthier choice options, especially for developing children.

As for the type of formal establishment, there was a predominance of snack bars. This type of trade outlet favors greater access to high energy density food. Therefore, the territories analyzed are characterized by an insufficiency of desirable establishments for healthier food choices, considering that places with a more significant presence of markets and fruit and vegetables are food environments less conducive to obesity⁸8 Costa BVL, Oliveira CDL, Lopes ACS. Ambiente alimentar de frutas e hortaliças no território do Programa da Academia da Saúde. Cad Saude Publica 2015; 31(Supl. 1):S1-S11.^,3434 Leung CW, Laraia BA, Kelly M, Nickleach D, Adler NE, Kushi LH, Yen IH. The Influence of Neighborhood Food Stores on Change in Young Girls' Body Mass Index. Am J Prev Med 2011; 41(1):43-51.^,3535 Chen HJ, Wang Y. Changes in the neighborhood food store environment and children's body mass index at peri-puberty in the United States. J Adolesc Health 2016; 58(1):111-118..

Since 2009, the municipality of Niterói has a Law that prohibits the sale and advertising of products contributing to childhood obesity in canteens and snack bars installed in school units that are part of the municipal education system³⁶36 Prefeitura Municipal de Niterói. Lei nº 2659, de 19 de novembro de 2009. Proíbe a comercialização, a aquisição, a distribuição e a publicidade de produtos que contribuem para a obesidade infantil e dá outras providências. Niterói 2009; 19 nov.. However, as in other States and Municipalities with legal provisions, the challenge concerns street vendors who sell treats around public and private schools.

A study carried out in the city of Santos-SP observed a predominance of informal establishments in the vicinity of public schools that were characterized by the exclusive sale of processed and ultraprocessed foods¹¹11 Leite FHM, Oliveira MA, Cremm EC, Abreu DSC, Maron LR, Martins PA. Availability of processed foods in the perimeter of public schools in urban areas. J Pediatr 2012; 88(4):328-334.. Similar studies that evaluated the proximate surroundings of schools in New Zealand³⁷37 Day PL, Pearce J. Obesity-Promoting Food Environments and the Spatial Clustering of Food Outlets Around Schools. Am J Prev Med 2011; 40(2):113-121. and New York³⁸38 Neckerman KM, Bader MD, Richards CA, Purciel M, Quinn JW, Thomas JS, Warbelow C, Weiss CC, Lovasi GS, Rundle A. Disparities in the food environments of New York City public schools. Am J Prev Med 2010; 39(3):195-202. identified an agglomeration of businesses characterized by the sale of high-calorie foods such as fast-food and convenience stores, reinforcing the findings of this study.

The analysis of food preparations according to the level of processing in the Food Guide’s perspective is a complex task for researchers, when ultraprocessed, processed and fresh foods/ingredients are used in the same preparation. In this study, food preparations were evaluated according to the rate of energy in each category, of which preparations with a high rate of ultraprocessed foods (above 15%) were identified. Moreover, even fresh foods can be added with ultraprocessed foods, evidenced in this study by tapioca stuffed with ham and by popcorn seasoned with condensed milk.

The excessive use of culinary ingredients, such as sugar and oils, opposes the recommendations of the food guide and mischaracterizes preparations that are considered healthy a priori, such as the case of sugar-added fruit juice and fruit milkshake/smoothie, also identified in this study. The use of this ingredient stood at increasing levels throughout Brazil³⁹39 Levy RB, Claro RM, Bandoni DH, Mondini L, Monteiro CA. Disponibilidade de "açúcares de adição" no Brasil: distribuição, fontes alimentares e tendência temporal. Rev Bras Epidemiol 2012; 15(1):3-12., exceeding the recommendations of the World Health Organization (WHO), which advises that the contribution of daily added sugar should not exceed 10% in total calories⁴⁰40 World Health Organization (WHO). Diet, nutrition and the prevention of chronic diseases report of a joint WHO/FAO expert consultation. Geneva: WHO; 2003..

Strategies for implementing public policies to regulate the sale of ultraprocessed foods and beverages, known as competitive foods, have been attempted in different developed countries⁴¹41 Sanchez-Vaznaugh EV, Sánchez BN, Crawford PB, Egerter S. Association between competitive food and beverage policies in elementary schools and childhood overweight/obesity trends differences by neighborhood socioeconomic resources. JAMA Pediatr 2015; 169(5):e150781.. In Brazil, some of them have been discussed and implemented with varying degrees of success, such as nutrition labeling, the regulation of food advertising, and the agreements between the Brazilian Food Industry Association and the Ministry of Health to reduce sodium, trans fats, and sugar. A significant achievement in this regard was the recent publication by the National Health Surveillance Agency (ANVISA) of RDC nº 332, of December 23, 2019, which defines the requirements for hydrogenated fats and prohibits the production, import, use and supply of partially hydrogenated oils and fats for use in foods and foods formulated with these ingredients⁴²42 Agência Nacional de Vigilância Sanitária (ANVISA). Resolução da Diretoria Colegiada - RDC nº 332, de 23 de dezembro de 2019. Define os requisitos para uso de gorduras trans industriais em alimentos. 2019..

Another significant regulatory advance for the promotion of healthy eating was the Public Consultation (CP) addressing the proposed Resolution of the Collegiate Board on nutrition labeling to facilitate the consumer’s understanding of the nutritional information⁴³43 Agência Nacional de Vigilância Sanitária (ANVISA). Consulta Pública nº 707 de 13/09/2019. Proposta de Resolução da Diretoria Colegiada que dispõe sobre a rotulagem nutricional de alimentos embalados. Diário Oficial da União; 16 set. 2019.. Food advertising regulation should gain prominence in the government’s public agenda considering the advances and setbacks obtained, due to the conflicts of interest on this topic in Brazil⁴⁴44 Henriques P, Dias PC, Burlandy L. A regulamentação da propaganda de alimentos no Brasil: convergências e conflitos de interesses. Cad Saude Publica 2014; 30(6):1219-1228..

Another strategy that can encourage better choices is subsidizing healthy foods and taxing unhealthy foods based on the proportion of sugar, fat, and calories⁴⁵45 Seiders K, Petty RD. Obesity and the role of food marketing: a policy analysis of issues and remedies. J Public Policy Marketing 2004; 23(2):153-169.. In this regard, the WHO recommends increasing taxes on soft drinks and sugary drinks to combat the growth in overweight and obesity rates worldwide⁶6 World Health Organization (WHO). Report of the commission on ending childhood obesity. Washington DC: WHO; 2016..

Modifying the food environment through regulatory measures is not the only way to reduce the consumption of ultraprocessed foods. Educational strategies are equally important and necessary as the training of canteen owners and continuous EAN actions that must be included in the schools’ educational project. Activities that arouse the reflection of the participants, such as workshops for the development of culinary practices and the use of vegetable gardens as a learning aid, can help to face the current scenario of replacing fresh foods with highly processed foods, enabling the understanding of food as social practice, promoting increased recognition of the relevance of fruit and vegetable consumption by students, and increasing their motivation to try out these foods⁴⁶46 Castro IRR. Desafios e perspectivas para a promoção da alimentação adequada e saudável no Brasil. Cad Saude Publica 2015; 31(1):7-9.

47 Lalonde B, Robitaille E. L'environnementbâtiautour des écoles et les habitudes de vie des jeunes: état des connaissances et portrait du Québec, Montréal. Québec: Institut national de santé publique du Québec; 2014.

48 Harrison F, Jones AP. A framework for understanding school based physical environmental influences on childhood obesity. Health Place 2012; 18(3):639-648.^-4949 Vet E, Wit JB, Luszczynska A, Stok FM, Gaspar T, Pratt M, Wardle J , Ridder DT. Access to excess: how do adolescents deal with unhealthy foods in their environment? Eur J Public Health 2013; 23(5):752-756..

A study that evaluated the school environment’s influence on the nutritional status of schoolchildren found that schools with a more significant number of snack bars and food advertisements in the territory had a higher proportion of children with obesity⁵⁰50 Lourenço ALP, Vieira JL, Rocha CMM, Lima FF. Influência da ambiência escolar no estado nutricional de pré-escolares de Macaé, Rio de Janeiro. Cien Saude Colet 2019; 24(7):2399-2410.. Some studies call the environment “obesogenic” when the availability of healthy foods is scarce or nonexistent, when it has an ample supply of ultraprocessed foods and advertising exposure, besides discouraging physical activity¹¹11 Leite FHM, Oliveira MA, Cremm EC, Abreu DSC, Maron LR, Martins PA. Availability of processed foods in the perimeter of public schools in urban areas. J Pediatr 2012; 88(4):328-334.^,5151 Duran AC, Almeida SL, Latorre MR, Jaime PC. The role of the local retail food environment in fruit, vegetable and sugar-sweetened beverage consumption in Brazil. Public Health Nutr 2016; 19(6):1093-10102.

52 Pessoa MC, Mendes LL, Caiaffa WT, Malta DC, Velásquez-Meléndez G. Availability of food stores and consumption of fruit, legumes and vegetables in a Brazilian urban area. Nutr Hosp 2014; 31(3):1438-1443.

53 Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating Healthy Food and Eating Environments: Policy and Environmental Approaches. Annu Ver Public Health 2008; 29: 253-272.^-5454 Fisberg M, Maximino P, Kain J, Kovalskys I. Obesogenic environment - intervention opportunities. J Pediatr 2016; 92(3 Supl. 1):S30-S39.. In this sense, it is difficult to adopt and maintain dietary recommendations for the prevention and control of obesity in an environment conducive to habits and attitudes contrary to these practices.

Therefore, the regulation of the school food environment is a strategy for the promotion of a healthy diet, considering that the foods that underlie this environment may have a protective or promoting effect on obesity⁵⁵55 Lopes ACS, Menezes MC, Araujo ML. O ambiente alimentar e o acesso a frutas e hortaliças: "Uma metrópole em perspectiva". Saude Soc 2017; 26(3):764-773.^,5656 Canella DS, Louzada MLC, Claro RM, Costa JC, Bandoni DH, Levy RB, Martins APB. Consumo de hortaliças e sua relação com os alimentos ultraprocessados no Brasil. Rev Saude Publica 2018; 52(50):1-11.. Nevertheless, health promotion and healthy eating actions cannot do without recognizing the food environment, as they support the individual on strategies to make better choices in these environments.

The WHO Commission for the End of Childhood Obesity has published a report recognizing that many children live in environments that promote excessive weight gain and inadequate eating practices. They recommend the promotion of healthy school environments as one of the main actions to reduce childhood obesity and health problems associated with this disease⁶6 World Health Organization (WHO). Report of the commission on ending childhood obesity. Washington DC: WHO; 2016.. The Strategic Action Plan for Coping with Chronic Non-Communicable Diseases 2011-2022, published by the Ministry of Health of Brazil, also recognizes the school as favorable equipment for the promotion of healthy eating and physical activity in the recommendations geared to children⁵⁷57 Brasil. Ministério da Saúde (MS). Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. Brasília: MS; 2011..

The sale of foods with high energy value and high sugar, sodium and fat content in canteens and the school environment, can discourage the acceptance of school meals and affect the possible impacts of the EAN actions proposed by the PNAE in public schools. Likewise, in private schools, these foods compete with healthy eating protective factors, such as efforts to regulate canteens and the inclusion of healthy eating in the school’s educational project.

The choice for fresh foods depends on availability and accessibility. Therefore, there is a need to develop strategies to promote the protection of the school environment concerning the sale of ultraprocessed foods and, notably, to support the actions to promote healthy eating already implemented in schools. The strengthening of programs such as the PNAE can expand the reach of equipment that promote the triggering of positive changes in the food system, considering the greater access to healthy foods⁴⁶46 Castro IRR. Desafios e perspectivas para a promoção da alimentação adequada e saudável no Brasil. Cad Saude Publica 2015; 31(1):7-9..

Changes in dietary practices demand considering each case’s singularities and the specificities of the child development process that involves the construction of decision-making skills. On the other hand, the indiscriminate sale of ultraprocessed products around public and private schools indicates the relevance of public policies that make environments more conducive to the adoption of healthy choices, primarily State regulatory actions. Moreover, it warns about the relevance of assessing the environment in order to learn more about the school food environment, mainly because the topic is rarely addressed in the literature and can subsidize public policymakers to regulate the food environment of educational institutions to support, encourage and protect healthy eating habits and reduce the risk of childhood obesity. However, it has limitations arising from the lack of a validated instrument for assessing the school environment.

The reconfiguration of institutional environments requires joint action by several governmental spheres, intersectoral articulation, and social engagement to have a lasting impact on the transformation of dietary practices since they are socially constructed and integrated with sociocultural structures, systems, policies and standards⁹9 Swinburn B, Egger G, Raza F. dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental interventions for obesity. Prev Med 1999; 29(6):563-570.. It also requires the challenge of sensitizing school principals, canteen owners, and street vendors located near school entrances about the effects of their sold food on the health of children, who still do not have the critical capacity to make more healthy choices.

Conclusion

This study’s findings showed no significant difference between the foods sold around public and private schools. The food environment around the schools surveyed is characterized by the full availability of establishments that mainly sell ultraprocessed foods, favoring children’s exposure to an environment that encourages the consumption of these products, reinforcing the need for regulatory strategies. This indicates the widespread sale of ultraprocessed products in different urban spaces and social strata demanding universal public policies that affect this context. On the other hand, the school space is fundamental for establishing environments that promote healthy eating practices that enhance the integration of stimulating, supportive and protective actions in the light of the recommendations of the food guide for the Brazilian population.

Acknowledgments

We are grateful to the Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ) for the financial support, and students of the Grupo de Ensino, Pesquisa e Extensão em Alimentação e Saúde do Escolar (GEPASE/UFF), for their collaboration in data collection.

References

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