Abstract

The aim of this study was to analyze the association between adherence to school meals and the co-occurrence of the regular consumption of healthy and unhealthy eating markers among Brazilian adolescents. Data from 67,881 adolescents in Brazilian public schools who participated in the 2015 National School Health Survey, were used. From the 7-day FFQ, the dependent variable was constructed, co-occurrence of regular consumption (≥ 5x/week) of healthy and unhealthy food markers, which was categorized as regular consumption of none, one or two, or three eating markers. We performed an ordinal logistic regression with adjustment for sociodemographic, eating habits outside of school, and school characteristics variables. The prevalence of the co-occurrence of the regular consumption of three healthy eating markers was 14.5%, and that of three unhealthy markers was 4.9%. High adherence to school meals (every day) was positively associated with regular consumption of healthy eating markers and inversely associated with regular consumption of unhealthy eating markers. The school meals provided by PNAE contribute to the promotion of healthy eating habits among Brazilian adolescents.

Key words:
School food; Adolescents; Food consumption; Healthy Surveys; Public Policy

Introduction

Adolescents are a nutritionally vulnerable population group due to the greater energy and nutrient requirements at this stage of life and their susceptibility to external influences, as school, media and friendships¹1 Wang D, Fawzi WW. Impacts of school feeding on educational and health outcomes of school-age children and adolescents in low-A nd middle-income countries: protocol for a systematic review and meta-analysis. Syst Rev 2020; 9(1):4-11.. However, this group’s eating habits are often unhealthy, characterized by low consumption of fruits and vegetables, and high consumption of ultra-processed foods (UPFs)²2 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de Orçamentos Familiares 2017-2018: análise de consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2020.^,33 Rodrigues RM, Souza AM, Bezerra IN, Pereira RA, Yokoo EM, Sichieri R. Evolução dos alimentos mais consumidos no Brasil entre 2008-2009 e 2017-2018. Rev Saude Publica 2021; 55(Supl. 1):4s. with their consumption is associated with several chronic diseases, as such obesity, cardiovascular and metabolic diseases, cancer, depression and gastrointestinal disorders⁴4 Monteiro CA, Cannon G, Lawrence M, Costa Louzada ML, Machado PP. Ultra-processed foods, diet quality, and health using the NOVA classification system. Rome: FAO; 2019..

Inadequate eating habits during adolescence are one of the main risk factors for the early development of chronic non-communicable diseases, with serious repercussions both in adolescence¹1 Wang D, Fawzi WW. Impacts of school feeding on educational and health outcomes of school-age children and adolescents in low-A nd middle-income countries: protocol for a systematic review and meta-analysis. Syst Rev 2020; 9(1):4-11. (WHO, 2005) and adulthood⁵5 Craigie AM, Lake AA, Kelly SA, Adamson AJ, Mathers JC. Tracking of obesity-related behaviours from childhood to adulthood: a systematic review. Maturitas 2011; 70(3):266-284.. On the other hand, healthy habits acquired and consolidated in adolescence can strongly perpetuate into adult life⁵5 Craigie AM, Lake AA, Kelly SA, Adamson AJ, Mathers JC. Tracking of obesity-related behaviours from childhood to adulthood: a systematic review. Maturitas 2011; 70(3):266-284., and a school is a crucial place for the implementation of strategies and policies to promote healthy eating habits⁶6 Centers for Disease Control and Prevention (CDC). School health guidelines to promote healthy eating and physical activity. MMWR Recomm Rep 2011; 60(RR-5):1-76..

Several countries have implemented school food programs based on the hypothesis that it can be an effective intervention to improve the quality of students’ diets, with positive effects seen in low- and middle-income countries⁷7 World Health Organizaion (WHO). Nutrition in adolescence : issues and challenges for the health sector : issues in adolescent health and development. Genebra: WHO; 2005.. In Brazil, the National School Food Program (PNAE, in the Portuguese acronym) aims to build healthy eating habits through food and nutrition education actions and the provision of free meals that meet all students’ nutritional needs in the public primary and secondary education network throughout the school year. The menus prepared under the PNAE are planned based on fresh foods, sugar-sweetened beverages are forbidden, and the offer of ultra-processed foods rich in sodium or saturated fats is restricted. It is also mandatory to purchase at least 30% of food from family farming⁸8 Brasil. Resolução/CD/FNDE no 38, de 16 de julho de 2009. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no Programa Nacional de Alimentação Escolar - PNAE. Diário Oficial da União 2009; 16 jul..

Studies have found an association between adherence to school meals and improved diet quality among Brazilian students⁹9 Azeredo CM, Rezende LF, Canella DS, Claro RM, Peres MF, Luiz OC, França-Junior 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 (Baltim) 2016; (88):73-79.

10 Boklis-Berer M, Rauber F, Azeredo CM, Levy RB, Louzada MLDC. School meals consumption is associated with a better diet quality of Brazilian adolescents: results from the PeNSE 2015 survey. Public Health Nutr 2021; 24(18):6512-6520.

11 Horta PM, Carmo AS, Junior EV, Santos L. Consuming school meals improves Brazilian children's diets according to their social vulnerability risk. Public Health Nutr 2019; 22(14):2714-2719.^-1212 Locatelli NT, Canella DS, Bandoni DH. Positive influence of school meals on food consumption in Brazil. Nutrition 2018; 53:140-144.. However, none of them assessed the co-occurrence of the consumption of healthy and unhealthy markers associated with adherence to school meals among adolescents from Brazilian public schools.

Therefore, this study aims to analyze the association between the co-occurrence of the regular consumption of healthy and unhealthy eating markers and adherence to school meals among Brazilian students from public schools.

Methods

We used data from the third edition of the National School-based Health Survey (PeNSE) conducted in 2015, which is a cross-sectional study representative of Brazil, among ninth-graders enrolled at and attending public and private schools (102,072), covering the 27 federative units, including capitals and municipalities. Data were collected between April and September 2015 using a smartphone containing a structured and self-administered questionnaire divided into thematic modules. More detailed information on the sample size can be found in the survey publication¹³13 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar 2015. Rio de Janeiro: IBGE; 2016..

This study evaluated only students from public schools offering school meals (67,881), considering that the independent variable of interest was students’ adherence to school food of the National School Food Program (PNAE), which are all students enrolled in public schools⁹9 Azeredo CM, Rezende LF, Canella DS, Claro RM, Peres MF, Luiz OC, França-Junior 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 (Baltim) 2016; (88):73-79..

Food consumption was assessed using a food frequency questionnaire (FFQ) in which adolescents could answer that they had not consumed any food or indicate the frequency from one to seven days, considering the last seven days before the interview. From a total of six food groups included in the FFQ, in this study, the following food groups were investigated: beans, vegetables, fruits, fried salted, soft drinks, and ultra-processed (e.g., hamburger, ham, bologna, salami, sausages, packaged snacks, instant noodles, and crackers). The first three food groups were considered healthy eating markers, and the others were considered unhealthy eating markers, according to the classification adopted by IBGE¹³13 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar 2015. Rio de Janeiro: IBGE; 2016..

From the responses for each food, food consumption was categorized as regular (≥ 5 x/week) and nonregular (< 5 x/week). Finally, two scores were created based on the simultaneity of foods consumed by each student, one for the consumption of healthy eating markers and another for the consumption of unhealthy eating markers, which were categorized into three categories: no consumption, regular consumption of one or two food groups or regular consumption of three eating markers.

The adherence to school meals was assessed by the question “Do you usually eat the meal (brunch/lunch) offered by the school?”, with the categorized answers into (1) high adherence - considering the answer “Yes, every day”; (2) unsatisfactory adherence - considering the answers “Yes, 3 to 4 days a week”; “Yes, 1 to 2 days a week” and “rarely”, and (3) nonadherence - considering the answer “No”. Sociodemographic, eating habits outside of school, and school characteristics variables were used to describe the sample and as covariates for adjusting the associations. Regarding school and sociodemographic characteristics, the variables included were the macroregion of the municipality (north, northeast, southeast, south, and midwest), school’s geographic location (urban or rural), presence of canteen at school (yes or no), sex (male or female), age (groups: ≤ 13 years; 14 to 15 years; ≥ 16 years), paid work (yes or no), living with the parents (both of them, only mother, only father, neither of them), race/skin color (white, black, yellow, brown, and indigenous) and socioeconomic level (tertiles - low, medium, and high).

The socioeconomic level variable was built on the following reported items: owning a landline, mobile phone, computer, internet, car, motorcycle, bathroom with shower at home, and maid on three or more days a week. A weight was assigned to each item, which was the inverse of the frequency of ownership or presence in the total sample evaluated. Each adolescent’s score was obtained by adding the individual items’ weights, which were later divided into three tertiles¹⁴14 Levy R, Castro IRR, Cardoso LO, Tavares LF, Sardinha LMV, Gomes FS, Costa AWN. Consumo e comportamento alimentar entre adolescentes brasileiros: Pesquisa Nacional de Saúde do Escolar. Cien Saude Colet 2010; 15(Supl. 2):3085-3097.. Multiple imputation by chained equations (MICE) was performed for the variable maternal schooling, which showed a 25% loss of information, to assign numerical values to the variable¹⁵15 Royston P, White IR. Journal of Statistical Software Multiple Imputation by Chained Equations (MICE): Implementation in Stata. J Stat Softw 2011; 45(4):1-20. Predictive variables for imputation were considered: gender, household assets (car, landline, cell phone, number of bathrooms at home), and services (housemaid and internet access at home).

The following variables were considered eating habits outside of school: having lunch or dinner with the parents or guardian, eating while watching television or studying, having breakfast, and having meals at fast-food restaurants. These variables were dichotomized: (1) Not regularly - considering the following answers: no; rarely; 1 to 2 days a week; and 3 to 4 days a week and (2) Regular - for the answers: 5-6 days a week; and every day.

The proportion of co-occurrence of the regular consumption of healthy and unhealthy eating markers was estimated using a Venn diagram. A descriptive analysis of the sociodemographic characteristics, eating habits outside of school, and school characteristics were performed for the general sample. Percentages of co-occurrence of the regular consumption of healthy and unhealthy eating markers and their respective 95% confidence intervals (CIs) were estimated according to adherence to school meals, and statistical significance was assessed by nonoverlapping confidence intervals. Multiple ordinal logistic regression models were used to test the association between the co-occurrence of the regular consumption of healthy and unhealthy eating markers (outcome) and adherence to school meals (exposure), adjusting for potential confounders. The variables included in the adjusted model were identified by constructing the directed acyclic graph (DAG) in the program daggity version 3.0¹⁶16 Textor J, Hardt J, DAGitty: A graphical tool for analyzing causal diagrams. Epidemiology 2011; 22(5):745.. The minimum adjustment identified included sex, age, socioeconomic level, living with parents, paid work, having breakfast, eating while studying or watching TV, having meals with parents or guardians, having meals at fast-food restaurants, macroregion of the municipality, school’s geographic location, and presence of canteen (Figure 1).

Multiple models were developed for the co-occurrence of the regular consumption of healthy eating markers and the co-occurrence of the regular consumption of unhealthy eating markers, considering “not regularly consuming any health/unhealthy food” as the reference category.

The National Research Ethics Commission (CONEP) approved PeNSE on March 30, 2015 (registration no. 1.006.467). All analyses were performed using Stata version 14.2 for Windows, considering the complex design of the sample.

Results

Approximately 52% of the 67,881 adolescents attending public schools were female, most of them were aged between 14 and 15 years old, did not engage in paid work, lived with their parents, resided in urban areas and attended schools without canteen. Regarding adherence to school meals, 22.0% showed high adherence to school meals (every day), 47.3% showed unsatisfactory adherence, and 30.8% had nonadherence (Table 1).

The prevalence of the co-occurrence of the regular consumption (≥ 5x/week) of the three healthy and unhealthy eating markers was 14.5% and 4.9% among students, respectively. Slightly more than half of the adolescents (52.6%) reported not regularly consuming any of the unhealthy eating markers, and 21.7% reported not regularly consuming any of the healthy assessed eating markers (Figure 2).

A lower proportion of adolescents with high adherence to school meals reported not regularly consuming any of the healthy food markers assessed, and a higher proportion reported regularly consuming the three healthy eating markers when compared to adolescents with unsatisfactory adherence and nonadherence.

A higher proportion of adolescents with high and unsatisfactory adherence to school meals reported not consuming any unhealthy food markers regularly, and a lower proportion of adolescents reported regularly consuming three of those unhealthy food markers assessed when compared to adolescents who did not adhere to school meals. No statistically significant difference was found in the consumption of one or two healthy and unhealthy eating markers (Figure 3).

A positive association between high adherence to school meals and co-occurrence of the regular consumption of healthy eating markers was observed when compared with nonadherence (OR: 1.25; 95%CI: 1.15-1.36) in the adjusted ordinal logistic regression model. Regarding the co-occurrence of the regular consumption of unhealthy food markers, a negative association was observed with high (OR: 0.78; 95%CI: 0.72-0.84) and unsatisfactory (OR: 0.84; 95%CI: 0.79-0.90) adherence to school meals when compared with nonadherence (Table 2).

Discussion

The positive association between the co-occurrence of the regular consumption of healthy eating markers and adherence to school meals observed in this study suggest that PNAE are associated with healthy dietary habits among Brazilian students, similar to that found in Brazilian national surveys⁹9 Azeredo CM, Rezende LF, Canella DS, Claro RM, Peres MF, Luiz OC, França-Junior 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 (Baltim) 2016; (88):73-79.

10 Boklis-Berer M, Rauber F, Azeredo CM, Levy RB, Louzada MLDC. School meals consumption is associated with a better diet quality of Brazilian adolescents: results from the PeNSE 2015 survey. Public Health Nutr 2021; 24(18):6512-6520.

11 Horta PM, Carmo AS, Junior EV, Santos L. Consuming school meals improves Brazilian children's diets according to their social vulnerability risk. Public Health Nutr 2019; 22(14):2714-2719.^-1212 Locatelli NT, Canella DS, Bandoni DH. Positive influence of school meals on food consumption in Brazil. Nutrition 2018; 53:140-144. and Belo Horizonte, Minas Gerais, Brazil. Data from other countries also showed that free school meals are positively associated with the quality of students’ diet and food security¹⁷17 Cohen JFW, Hecht AA, McLoughlin GM, Turner L, Schwartz MB. Universal school meals and associations with student participation, attendance, academic performance, diet quality, food security, and body mass index: a systematic review. Nutrients 2021; 13(3):911.. A Brazilian study assessed 2,500 school meal menus by a quality index that was previously validated and found that only 20% presented low quality¹⁸18 Camargo RGM, Caivano SDA, Domene, SMA. Qualitative evaluation of school meal menus offered in brazilian municipalities. Cien Saude Colet 2021; 26(6):2207-2213..

It is worth mentioning that in the year of the PENSE 2015 data collection, some rules to improve the school menus had already been implemented. Since 2009, it has been mandatory to provide at least three servings of fruits and vegetables per week (200 g/week), and there are limits on the amounts of sugar, sodium, and fats in the daily preparations for the school meal. Furthermore, low nutritional content drinks (soft drinks and artificial refreshments, drinks or concentrates based on guarana or currant syrup, ready-to-drink teas, and other similar drinks) are prohibited, and ultra-processed foods (canned food, sweets, compound foods, semi-ready or ready-made preparations consumption, or concentrated foods) are restricted⁸8 Brasil. Resolução/CD/FNDE no 38, de 16 de julho de 2009. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no Programa Nacional de Alimentação Escolar - PNAE. Diário Oficial da União 2009; 16 jul..

Additionally, aiming to encourage the voluntary adoption of healthy food practices and students’ choices, the legislation provides the inclusion of Food and Nutrition Education actions in the school environment. Another rule implemented to improve the quality of school menus was to destinate 30% of the PNAE budget for purchasing fresh and minimally processed foods from family farming¹⁹19 Brasil. Resolução n. 6, de 8 de maio de 2020. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar 2020 - PNAE. Brasil. Diário Oficial da União 2020; 8 maio., supporting the sustainable food systems. Thus, the study findings are in line with PNAE legislation in force in the year of data collection and suggest that the aims of PNAE to promote healthy habits among schoolchildren are being achieved.

Recently, the rules for the planning of school menus were updated, making progress more rigorous. It was established that the PNAE resources should be spent according to criteria based on food processing, restricting even more purchases of ultra-processed foods¹⁹19 Brasil. Resolução n. 6, de 8 de maio de 2020. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar 2020 - PNAE. Brasil. Diário Oficial da União 2020; 8 maio., based on the Dietary Guideline for the Brazilian Population²⁰20 Brasil. Ministério da saude (MS). Guia Alimentar para a População Brasileira Guia Alimentar para a População Brasileira. Brasília: MS; 2014.. This is important progress to improve the school meals offered by PNAE and could result in an even better positive impact on adolescents’ eating habits.

In this context, we highlighted that the update of the acquisition food by PNAE and the results of this study show the important role of PNAE to mitigate the global syndemic of obesity, malnutrition and climate change and to reach the Sustainable Development Goals for 2030, which outlines strategies such as the promotion of healthier eating behaviors and the adoption of sustainable food systems²¹21 Development Initiatives. Global Nutrition Report 2017: Nourishing the SDGs. Bristol: Development Initiatives; 2017., since the school meals’ guideline encourages the consumption of fresh or minimally processed foods from sustainable agriculture and the disincentive to the consumption of ultra-processed foods.

Despite the positive findings of this study and the fact that the school meals in Brazil are free of charge, it is important to highlight that the proportion of adolescents who consume school meals five times/week is low (22.0%), similar to other Brazilian studies that also observed a low consumption of school meals¹⁰10 Boklis-Berer M, Rauber F, Azeredo CM, Levy RB, Louzada MLDC. School meals consumption is associated with a better diet quality of Brazilian adolescents: results from the PeNSE 2015 survey. Public Health Nutr 2021; 24(18):6512-6520.^,2222 Cesar JT, Valentim EA, Almeida CCB, Schieferdecker MEM, Schmidt ST, 2018. School Food in Brazil and the United States: an integrative review. Cien Saude Colet 2018; 23(3):991-1007.

23 Froelich M, Souza BSN, Andrade ACS, Muraro AP. School environment and adherence to school meals among Brazilian public-school adolescents. Rev Chil Nutr 2021; 48(5):732-740.^-2424 Honório OS, Rocha LL, Fortes MICM, Carmo AS, Cunha CF, Oliveira TRPR, Mendes LL. Consumption of school meals provided by pnae among brazilian public school adolescents. Rev Chil Nutr 2020; 47(5):765-771..

One of those main factors associated with the consumption of school meals is socioeconomic conditions, with higher consumption of school meals among students with worse socioeconomic conditions²⁴24 Honório OS, Rocha LL, Fortes MICM, Carmo AS, Cunha CF, Oliveira TRPR, Mendes LL. Consumption of school meals provided by pnae among brazilian public school adolescents. Rev Chil Nutr 2020; 47(5):765-771.. Even though school meals are offered to all students, the idea that the consumption of school meals is related to the condition of poverty still persists in the daily life of schools among the entire school community (students, teachers, directors, lunch ladies and nutritionists). In this way, a stigmatized image is attributed to students who consume the meals offered by school²⁵25 Silva EO, Amparo-Santos L, Dantas Soares M. Alimentação escolar e constituição de identidades dos escolares: da merenda para pobres ao direito à alimentação. Cad Saude Publica 2018; 34(4):e00142617..

Other issues involving the food preferences of students and the presence of competitive food inside the school are also considered main factors for low adherence to school meals²⁴24 Honório OS, Rocha LL, Fortes MICM, Carmo AS, Cunha CF, Oliveira TRPR, Mendes LL. Consumption of school meals provided by pnae among brazilian public school adolescents. Rev Chil Nutr 2020; 47(5):765-771.. In Brazil, public schools may have canteens, which may be regulated or not by local governments²⁶26 Instituto Brasileiro de Defesa do Consumidor (IDEC). Alimentação saudável nas escolas: guia para municípios. São Paulo: IDEC; 2018.. Additionally, it is common to find alternative food outlets around schools⁹9 Azeredo CM, Rezende LF, Canella DS, Claro RM, Peres MF, Luiz OC, França-Junior 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 (Baltim) 2016; (88):73-79.^,1313 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar 2015. Rio de Janeiro: IBGE; 2016.^,2727 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.. The presence of canteens²⁸28 Noll PRS, Noll M, Abreu LC, Baracat EC, Silveira EA, Sorpreso ICE. Ultra-processed food consumption by Brazilian adolescents in cafeterias and school meals. Sci Rep 2019; 9(9):7162. and alternative sale outlets¹³13 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar 2015. Rio de Janeiro: IBGE; 2016. in the school environment is associated with higher consumption of ultra-processed foods in Brazilian adolescents and lower consumption of school meals provided by PNAE²¹21 Development Initiatives. Global Nutrition Report 2017: Nourishing the SDGs. Bristol: Development Initiatives; 2017.^,2323 Froelich M, Souza BSN, Andrade ACS, Muraro AP. School environment and adherence to school meals among Brazilian public-school adolescents. Rev Chil Nutr 2021; 48(5):732-740.^,2424 Honório OS, Rocha LL, Fortes MICM, Carmo AS, Cunha CF, Oliveira TRPR, Mendes LL. Consumption of school meals provided by pnae among brazilian public school adolescents. Rev Chil Nutr 2020; 47(5):765-771.. The ultra-processed foods commercialized by canteens and alternative outlets in the school environment⁹9 Azeredo CM, Rezende LF, Canella DS, Claro RM, Peres MF, Luiz OC, França-Junior 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 (Baltim) 2016; (88):73-79.^,2727 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. are known as “competitive foods”, as they compete with school meals and are a barrier to healthy eating habits.

Currently, it has been observed that the diet quality of Brazilian adolescents is worsening²2 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de Orçamentos Familiares 2017-2018: análise de consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2020.^,33 Rodrigues RM, Souza AM, Bezerra IN, Pereira RA, Yokoo EM, Sichieri R. Evolução dos alimentos mais consumidos no Brasil entre 2008-2009 e 2017-2018. Rev Saude Publica 2021; 55(Supl. 1):4s., which was exacerbated by suspension of classes in schools due COVID-19²⁹29 Malta DC, Gomes CS, Barros MBA, Lima MG, Silva AG, Cardoso LSM, Werneck AO, Silva DRP, Ferreira APS, Romero DE, Freitas MIF, Machado ÍE, Júnior PRBS, Damacena GN, Azevedo LO, Almeida WS, Szwarcwald CL. A pandemia de COVID-19 e mudanças nos estilos de vida dos adolescentes brasileiros. Rev Bras Epidemiol 2021; 24:e210012.. Multiple challenges were faced related to execution of the PNAE during pandemic period, resulting in worsened health and nutrition indicators and advanced dietary inequalities³⁰30 Mendes LL, Canella DS, Araújo ML, Jardim MZ, Cardoso LDO, Pessoa MC. Food environments and the COVID-19 pandemic in Brazil: analysis of changes observed in 2020. Public Health Nutr 2022; 25(1):32-35. Doi:https://doi.org/10.1017/S1368980021003542
https://doi.org/https://doi.org/10.1017/... ^,3131 World Food Programme (WFP). The impact of COVID-19 on school feeding around the world. Rome: WFP; 2020.. Therefore, it emphasizes the need for governments to plan strategies and direct financial resources that aim to change this scenario. Another point that should be highlighted is the role of the PNAE in reducing possible disparities in access to and consumption of healthy foods, such as fruits and vegetables¹¹11 Horta PM, Carmo AS, Junior EV, Santos L. Consuming school meals improves Brazilian children's diets according to their social vulnerability risk. Public Health Nutr 2019; 22(14):2714-2719.. This becomes even more important in a context where healthy foods are becoming more expensive³²32 Maia EG, Passos CM, Levy RB, Martins APB, Mais LA, Claro RM. What to expect from the price of healthy and unhealthy foods over time? The case from Brazil. Public Health Nutr 2020; 23(4):579-588..

School meals offered by the PNAE can be a great ally to improve adolescents’ health since the findings of this study demonstrate its potential in the formation of healthy habits. However, the modification of the school food environment, such as limiting access to competitive foods by effective regulations and using strategies to enhance the palatability of the meals offered by PNAE, could result in a positive impact on eating practices in Brazilian students, as was already observed in other countries³³33 Cohen JFW, Hecht AA, Hager ER, Turner L, Burkholder K, Schwartz MB. Strategies to improve school meal consumption: a systematic review. Nutrients 2021; 13(10):3520.. It is also necessary to eliminate the stigma associated with school meals offered by the PNAE by recognizing it as a policy based on the human right to adequate food for everyone in the school community.

The PeNSE 2015 questionnaire did not assess quantities and the place where food was consumed, which can be considered a limitation of this study, as it cannot be ascertained that the consumption of healthy or unhealthy foods comes from school meals. Despite this, the school food environment is capable of influencing consumption outside of schoo^l6,19, and it was appointed that food consumption on school days is associated with healthier eating habits³⁴34 Lobo AS, Assis MAA, Leal DB, Borgatto AF, Vieira FK, Di Pietro PF, Kupek E. Empirically derived dietary patterns through latent profile analysis among Brazilian children and adolescents from Southern Brazil, 2013-2015. PLoS One 2019; 14(1):e0210425.. Furthermore, there is no information on the survey instrument about food purchased in canteens and other places around the schools by adolescents, which would be relevant for this study. As PeNSE is carried out periodically, we believe it would be important to investigate further details about the school food environment in the next edition.

As a strength, the novelty of this study stands out when evaluating the association between the co-occurrence of the regular consumption of healthy and unhealthy eating markers and adherence to school meals in a representative sample of Brazilian school adolescents. The construction of the directed acyclic graph to identify potential confounders is a strength of the study as well.

In conclusion, the results of this study showed that high adherence was positively associated with regular consumption of healthy eating makers and inversely associated with regular consumption of unhealthy eating makers, reinforcing the crucial role of PNAE in encouraging healthy habits among Brazilian adolescents and its potential to mitigate the global syndemic. These data could be useful in decision-making regarding the direction of financial resources aimed at improving adolescent health and chronic disease prevention by public managers.

Acknowledgments

The authors are grateful to all students and school directors who participated in the National School Health Survey (2015), thus contributing to the development of this work. Also, we appreciate the support of the Universidade Federal do Mato Grosso and the Instituto Federal de Mato Grosso - Campus Juína.

References

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History