ABSTRACT

Objective:

This study aimed to verify the association between adherence to school meals provided by the National School Feeding Program and dietary patterns in adolescents from Brazilian public schools.

Methods:

Data from the 2019 National School Health Survey were used, with a nationally representative sample of Brazilian school adolescents (n=53,477; 13–17 years old). Food consumption of healthy and unhealthy food markers was obtained from a food consumption questionnaire. Regular consumption was considered ≥5 times/week. Latent class analysis was used to identify dietary patterns whose association with adherence to school meals was evaluated by multinomial logistic regression models, with adjustment for sociodemographic and eating behavior variables.

Results:

Three dietary patterns were identified: “unhealthy” — higher consumption of soft drinks and sweets (9.2% of adolescents); “healthy” — higher consumption of beans, vegetables, and fruits (27.1%); and “monotonous” — higher consumption of beans (63.7%). High adherence to school meals (every day) and unsatisfactory adherence (1–4 times/week) were positively associated with the healthy pattern even after adjustment for possible potential confounders (OR 1.37, 95%CI 1.23–1.52; OR 1.20, 95%CI 1.10–1.30, respectively).

Conclusion:

The results showed that the consumption of school meals offered by the National School Feeding Program can contribute to healthy eating habits among Brazilian adolescents.

Keywords:
Dietary patterns; Latent class analysis; Public policy; School feeding; Adolescents

RESUMO

Objetivo:

Este estudo teve como objetivo verificar a associação entre a adesão à alimentação escolar fornecida pelo Programa Nacional de Alimentação Escolar e os padrões alimentares em adolescentes de escolas públicas brasileiras.

Métodos:

Foram utilizados dados da Pesquisa Nacional de Saúde Escolar de 2019, com uma amostra nacionalmente representativa de adolescentes brasileiros (n=53.477; 13–17 anos). O consumo de alimentos marcadores saudáveis e não saudáveis foi obtido a partir de um questionário de consumo alimentar. O consumo regular foi considerado ≥5 vezes/semana. A análise de classes latente foi utilizada para identificar padrões alimentares cuja associação com a adesão à alimentação escolar foi avaliada por modelos de regressão logística multinomial, com ajuste para variáveis sociodemográficas e de comportamento alimentar.

Resultados:

Foram identificados três padrões alimentares: “não saudável” — maior consumo de refrigerantes e doces (9,2% dos adolescentes); “saudável” — maior consumo de feijão, vegetais e frutas (27,1%); e “monótono” — maior consumo de feijão (63,7%). Alta adesão à alimentação escolar (todos os dias) e adesão insatisfatória (1–4 vezes/semana) foram positivamente associadas ao padrão saudável, mesmo após ajuste para possíveis fatores de confusão (OR 1,37, IC95% 1,23–1,52; OR 1,20, IC95% 1,10–1,30, respectivamente).

Conclusão:

Os resultados mostraram que o consumo das refeições escolares oferecidas pelo Programa Nacional de Alimentação Escolar pode contribuir para hábitos alimentares saudáveis entre os adolescentes brasileiros.

Palavras-chave:
Padrões dietéticos; Análise de classes latentes; Política pública; Alimentação escolar; Adolescentes

INTRODUCTION

Inadequate nutrition during adolescence is one of the main risk factors for the early development of chronic non-communicable diseases, with a great impact on early life¹1. Nilson EAF, Ferrari G, Louzada MLC, Levy RB, Monteiro CA, Rezende LFM. The estimated burden of ultra-processed foods on cardiovascular disease outcomes in Brazil: a modeling study. Front Nutr 2022; 9: 1043620. https://doi.org/10.3389/fnut.2022.1043620
https://doi.org/10.3389/fnut.2022.104362... and serious repercussions in adult life. In recent years, the quality of the diet of the Brazilian population has diminished, characterized by an increase in the consumption of ultra-processed foods, especially among adolescents²2. 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 Saúde Pública 2021; 55 Supl 1: 4s. https://doi.org/10.11606/s1518-8787.2021055003406
https://doi.org/10.11606/s1518-8787.2021... ,³3. Instituto Brasileiro de Geografia e Estatística. Pesquisa de orçamentos familiares 2017-2018: análise de consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2020.. This scenario is concerning for public health, given that adolescents are considered a nutritionally vulnerable population group⁴4. World Health Organization. Adolescent health [Internet]. 2021 [cited on Jan 25, 2022]. Available at: https://www.who.int/health-topics/adolescent-health#tab=tab_1
https://www.who.int/health-topics/adoles... . Eating habits acquired and consolidated at this stage of life have a high potential to perpetuate in adult life⁵5. Craigie AM, Lake AA, Kelly SA, Adamson AJ, Tracking of obesity-related behaviours from childhood to adulthood: a systematic review. Maturitas 2011; 70(3): 266-84. https://doi.org/10.1016/j.maturitas.2011.08.005
https://doi.org/10.1016/j.maturitas.2011... .

School feeding programs are considered one of the most effective public health strategies in developed⁶6. 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. https://doi.org/10.3390/nu13030911
https://doi.org/10.3390/nu13030911... and low- and middle-income countries⁷7. Wang D, Shinde S, Young T, Fawzi WW. Impacts of school feeding on educational and health outcomes of school-age children and adolescents in low- and middle-income countries: a systematic review and meta-analysis. J Glob Health 2021; 11: 04051. https://doi.org/10.7189/jogh.11.04051
https://doi.org/10.7189/jogh.11.04051... to promote healthy habits. Well-structured feeding programs act directly on all axes of the global syndemic of obesity, malnutrition, and climate change⁸8. Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, et al. The global syndemic of obesity, undernutrition, and climate change: the Lancet Commission report. Lancet 2019; 393(10173): 791-846. https://doi.org/10.1016/S0140-6736(18)32822-8
https://doi.org/10.1016/S0140-6736(18)32... . The Brazilian National School Feeding Program (PNAE, Programa Nacional de Alimentação Escolar) is one of the largest programs in the world and is internationally recognized as a strategy for fighting obesity and promoting healthy eating⁹9. Kroth DC, Geremia DS, Mussio BR. National school feeding program: a healthy public policy. Cien Saude Colet 2020; 25(10): 4065-76. https://doi.org/10.1590/1413-812320202510.31762018
https://doi.org/10.1590/1413-81232020251... .

Through the PNAE, students can benefit from one up to three free meals a day school, depending on their age and time spent at school. Most adolescents in Brazil attend part-time schools, thus receiving one daily meal¹⁰10. Brasil. Ministério da Educação. Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira. Diretoria de Estatísticas Educacionais. Censo da educação básica. Notas estatísticas. Brasília: INEP; 2019.. The objective of the program is to develop healthy eating habits through food and nutrition education activities and the provision of meals that meet the nutritional needs of students in the public basic education network (kindergarten, elementary, and high school) throughout school year¹¹11. Brasil. Ministério da Educação. Fundo Nacional de Desenvolvimento da Educação. Resolução/CD/FNDE no 26, de 17 junho de 2013. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar – PNAE. Brasília: Diário Oficial da União Brasil; 2013.. The PNAE menus are planned by nutritionists based on fresh or minimally processed foods. Sugar-sweetened beverages are forbidden and ultra-processed foods rich in sodium or saturated fats are restricted¹¹11. Brasil. Ministério da Educação. Fundo Nacional de Desenvolvimento da Educação. Resolução/CD/FNDE no 26, de 17 junho de 2013. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar – PNAE. Brasília: Diário Oficial da União Brasil; 2013.,¹²12. Brasil. Ministério da Educação. Fundo Nacional de Desenvolvimento da Educação. Resolução no 6, de 08 de maio de 2020. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar – PNAE. Brasília: Diário Oficial da União Brasil; 2020.. PNAE legislation also determines that at least 30% of financial resources must be used to purchase food from family farmers¹¹11. Brasil. Ministério da Educação. Fundo Nacional de Desenvolvimento da Educação. Resolução/CD/FNDE no 26, de 17 junho de 2013. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar – PNAE. Brasília: Diário Oficial da União Brasil; 2013.

12. Brasil. Ministério da Educação. Fundo Nacional de Desenvolvimento da Educação. Resolução no 6, de 08 de maio de 2020. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar – PNAE. Brasília: Diário Oficial da União Brasil; 2020.-¹³13. Brasil. Ministério da Educação. Fundo Nacional de Desenvolvimento da Educação. Resolução CD/FNDE no 38, de 16 de julho de 2009. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar – PNAE. Brasília: Diário Oficial da União Brasil; 2009..

Previous studies conducted with children and adolescents suggest there is a relationship between adherence to the food offered by the PNAE and better quality of diet¹⁴14. Muraro AP, Froelich M, Rodrigues PRM, Cunha DB, Mendes LL, Andrade ACS, et al. Association of school meals and eating behavior, diet quality, food safety, and body mass index among Brazilian students: a systematic review. Cien Saude Colet 2024; 0173.

15. Azeredo CM, Rezende LFM, Canella DS, Claro RM, Peres MFT, Luiz OC, et al. Food environments in schools and in the immediate vicinity are associated with unhealthy food consumption among Brazilian adolescents. Prev Med 2016; 88: 73-9. https://doi.org/10.1016/j.ypmed.2016.03.026
https://doi.org/10.1016/j.ypmed.2016.03....

16. Lobo AS, Assis MAA, Leal DB, Borgatto AF, Vieira FK, Di Pietro PF, et al. Empirically derived dietary patterns through latent profile analysis among Brazilian children and adolescents from Southern Brazil, 2013-2015. PLoS One 2019; 14(1): e0210425. https://doi.org/10.1371/journal.pone.0210425
https://doi.org/10.1371/journal.pone.021...

17. Horta PM, Carmo AS, Verley Junior E, Santos LC. Consuming school meals improves Brazilian children’s diets according to their social vulnerability risk. Public Health Nutr 2019; 22(14): 2714-9. https://doi.org/10.1017/S1368980019001459
https://doi.org/10.1017/S136898001900145...

18. Bento BMA, Moreira AC, Carmo AS, Santos LC, Horta PM. A higher number of school meals is associated with a less-processed diet. J Pediatr (Rio J) 2018; 94(4): 404-9. https://doi.org/10.1016/j.jpedp.2017.12.003
https://doi.org/10.1016/j.jpedp.2017.12....

19. Boklis-Berer M, Rauber F, Azeredo CM, Levy RB, Louzada MLC. The adherence to school meals is associated with a lower occurrence of obesity among Brazilian adolescents. Prev Med. 2021; 150: 106709. https://doi.org/10.1016/j.ypmed.2021.106709
https://doi.org/10.1016/j.ypmed.2021.106... -²⁰20. Locatelli NT, Canella DS, Bandoni DH. Positive influence of school meals on food consumption in Brazil. Nutrition 2018; 53: 140-4. https://doi.org/10.1016/j.nut.2018.02.011
https://doi.org/10.1016/j.nut.2018.02.01... . Prior to this study, none evaluated this association using the identification of dietary patterns, which allows a better representation of the complexity of habits compared to the evaluation of the consumption of foods and isolated nutrients, recognizing that foods are consumed in combination.

Considering the importance and urgency in evaluating the effectiveness of public policies for the prevention and control of obesity, the objective of this study was to verify the association between adherence to school meals and dietary patterns in a representative sample of adolescents from Brazilian public schools.

METHODS

This is a cross-sectional study with data from the 2019 National School Health Survey (PeNSE, Pesquisa Nacional de Saúde do Escolar), with students from public and private schools in Brazil, carried out by the Brazilian Institute of Geography and Statistics (IBGE, Instituto Brasileiro de Geografia e Estatística) and the Ministries of Health and Education. The sample estimates are representative of Brazilian students from 13 to 17 years old (n=124,898), covering the 27 federative units, including capitals and other municipalities. However, considering the objective of this study, only data of students (n=54,096) from public schools that offered school meals were evaluated. After excluding no-respondents to questions regarding exposure and/or outcome of this study, the final sample corresponded to 53,477 students.

Data were collected between April and September of 2019 through a Mobile Collection Device (DMC, dispositivo móvel de coleta), which is a smartphone where structured questionnaires are stored. More detailed information on sample size design can be found in the survey publication²¹21. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar (PeNSE). Rio de Janeiro: IBGE; 2019..

The dependent variable was constructed from the weekly frequency (days/weeks) of food consumption of five food groups included on the 2019 PeNSE food consumption markers questionnaire: beans, vegetables, fruits, sweets (e.g. candies, sweets, chewing gums, and chocolates), and soft drinks. The first three items are healthy eating markers while the others are unhealthy eating markers, a classification adopted by IBGE²¹21. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar (PeNSE). Rio de Janeiro: IBGE; 2019.. The adolescents could answer that they did not consume or indicate the frequency that varied from 1–7 days. According to the answers for each food group, the consumption was categorized into regular (≥5 times/week) and non-regular (<5 times/week). Based on food consumption (regular or non-regular), dietary patterns were identified by a posteriori latent class analysis.

Latent class analysis (LCA) was conducted on the Polytomous Variable Latent Class Analysis (poLCA)²²22. Linzer DA, Lewis JB. poLCA: an R Package for polytomous variable latent class analysis. J Stat Softw 2011; 42(10): 1-18. https://doi.org/10.18637/jss.v042.i10
https://doi.org/10.18637/jss.v042.i10... package available in the library of R statistical software. The number of classes (patterns) was selected based on the lowest value of the Bayesian Information Criterion (BIC), Akaike Information Criterion (AIC), likelihood ratio (G²), and highest entropy value. Among the methodologies used to derive dietary patterns, the LCA, considered an “individual-centered” analytical technique, has the advantage of being able to group individuals into latent (unobservable) classes, which contain individuals similar to each other and different from individuals of other classes. Through this technique, it is possible to use standardized criteria to determine the most appropriate number of classes, allowing the grouping of individuals with similar patterns without overlapping, facilitating the interpretation of the results.

The independent variable of interest was adherence to school meals, which was constructed from the question of how many days in the last week the adolescent consumed the food provided by the school. Consumption for every school day was classified as “high adherence”, consumption for 1–4 days in the last week and rarely was “unsatisfactory”, and “non-adherence” when not consumed¹⁷17. Horta PM, Carmo AS, Verley Junior E, Santos LC. Consuming school meals improves Brazilian children’s diets according to their social vulnerability risk. Public Health Nutr 2019; 22(14): 2714-9. https://doi.org/10.1017/S1368980019001459
https://doi.org/10.1017/S136898001900145... ,²³23. Martins BG, Ricardo CZ, Machado PP, Rauber F, Azeredo CM, Levy RB. Fazer refeições com os pais está associado à maior qualidade da alimentação de adolescentes brasileiros. Cad Saúde Pública 2019; 35(7): e00153918. https://doi.org/10.1590/0102-311X00153918
https://doi.org/10.1590/0102-311X0015391... .

Socioeconomic and eating behavior characteristics were used to describe the sample and to adjust the associations (covariates), which were identified by constructing the directed acyclic graph (DAG) in the program DAGity version 3.0²⁴24. Textor J, Hardt J, Knüppel S. DAGitty: a graphical tool for analyzing causal diagrams. Epidemiology 2011; 22(5): 745. https://doi.org/10.1097/EDE.0b013e318225c2be
https://doi.org/10.1097/EDE.0b013e318225... (Figure 1). The minimum adjustment identified included sex (male and female); age (13–15 years and 16–17 years); living with parents (both of them, only mother, only father, neither of them); maternal schooling (complete higher education, complete secondary education/incomplete higher education, complete primary education/incomplete secondary education, incomplete primary education and no education); socioeconomic stratum (tertiles: low, medium, and high); school’s geographic location (urban or rural); and macroregion (North, Northeast, Southeast, South, and Midwest).

The socioeconomic level variable was constructed based on the following reported items: owning a car, mobile phone, internet, computer, motorcycle, bathroom with shower in the house, and the presence of a maid 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 tertiles²³23. Martins BG, Ricardo CZ, Machado PP, Rauber F, Azeredo CM, Levy RB. Fazer refeições com os pais está associado à maior qualidade da alimentação de adolescentes brasileiros. Cad Saúde Pública 2019; 35(7): e00153918. https://doi.org/10.1590/0102-311X00153918
https://doi.org/10.1590/0102-311X0015391... . Multiple imputations by chained equations (MICE) were performed for the variable maternal schooling, which showed a 21% loss of information, to assign numerical values to the variable²⁵25. Royston P, White IR. Multiple Imputation by Chained Equations (MICE): implementation in stata. J Stat Softw 2011; 45(4): 1-20. https://doi.org/10.18637/jss.v045.i04
https://doi.org/10.18637/jss.v045.i04... . Predictive variables for imputation were: gender, household assets (car, mobile phone, number of bathrooms at home), and services (maid and internet access at home), according to a previous study²⁶26. Azeredo CM, Rezende LFM, Canella DS, Claro RM, Castro IRR, Luiz OC, et al. Dietary intake of Brazilian adolescents. Public Health Nutr 2015; 18(7): 1215-24. https://doi.org/10.1017/S1368980014001463
https://doi.org/10.1017/S136898001400146... .

Regarding the variables on eating behavior, the following were considered: having meals (lunch or dinner) with parents or guardians; eating while watching television or studying; having breakfast; and having meals at fast-food restaurants. Based on the frequency of these behaviors, the variables were grouped into two categories: “regular” (≥5 days/week), and “non-regular” (0–4 days/week)²⁷27. Froelich M, Souza BSN, Andrade ACS, Rodrigues PRM, Cunha DB, Muraro AP. Adherence to school meals and co-occurrence of the healthy and unhealthy food markers among Brazilian adolescents. Cien Saude Colet 2023; 28(7): 1927-36. https://doi.org/10.1590/1413-81232023287.12462022
https://doi.org/10.1590/1413-81232023287... . The food purchases in the school canteen were grouped into three categories: “regularly” (≥3 days/week), “not regularly” (0–4 days/week), and “no” (no school canteen).

A descriptive analysis of dietary patterns (dependent variable) was carried out, according to sociodemographic characteristics and eating behavior (covariates), with a description of the proportion and respective 95% confidence intervals (95%CI). Multinomial regression models unadjusted and adjusted for confounding variables were used to evaluate the association between adherence to school meals and dietary patterns. The “monotonous” pattern was defined as a reference category in the regression models. The results were expressed in odds ratios (OR) and their respective 95%CI.

PeNSE was approved by the National Research Ethics Committee (Conep, Comissão Nacional de Ética em Pesquisa) in April 2019 (registration No. 3,249,268). RSudio software was used for LCA, and Stata version 14.2, for all other statistical analyses, considering the complex sample design.

RESULTS

Among the 53,477 evaluated adolescents, 52.6% were female, 63.1% were 13–15 years old, 53.5% lived with both parents, 49.4% were classified in the low socioeconomic stratum, 33.8% had mothers with complete secondary education or incomplete higher education, 92.4% attended schools in the urban area, and 40.1% were from the Southeast region. Regarding health behavior, 34.7% did not regularly buy food from the school canteen, 57.7% ate breakfast regularly, 69.5% had meals with their parents or guardians regularly, 58.3% ate while watching TV or studying, and 94.5% did not regularly eat at fast-food restaurants. It was observed that 30.3% adhered to school meals, 47.2% adhered unsatisfactorily, and 22.5% did not adhere (Table 1).

Models of two to six classes were identified through LCA. The model with three dietary patterns was selected because it was considered the best fit, with the lowest BIC, AIC, and G², and one of the highest entropy values (Table 2).

The first dietary pattern identified was “unhealthy”, characterized by the higher consumption of sweets and soft drinks, comprising 8.7% of the adolescents (95%CI 8.1–9.2). The second dietary pattern was “healthy”, which included 29.2% (95%CI 28.3–30.1) of the adolescents and was characterized by higher regular consumption of all evaluated healthy markers (beans, vegetables, and fruits). The third dietary pattern, “monotonous”, was the most prevalent comprising 62.1% (95%CI 61.3–63.0) of the adolescents and was characterized by those who regularly consumed only beans among the healthy markers evaluated (Table 1 and Figure 2).

The proportion of adolescents classified as having a “healthy” dietary pattern was higher among those with high adherence to school meals (31.9%; 95%CI 30.4–33.5) and unsatisfactory adherence (28.9%; 95%CI 27.8–30.1) when compared to those who did not consume (non-adherence: 26.0%; 95%CI 24.6–27.5). “Healthy” dietary pattern was significantly higher in adolescents who were male, younger, living with both parents, of high socioeconomic level, had mothers that completed high school, were residents of the Midwest and Southeast region, did not buy food in the school canteen or attended schools without a canteen, had breakfast regularly, had meals with parents/guardians regularly, and did not have meals while studying or watching television regularly (Table 1).

In the unadjusted model, a positive association was observed between high adherence to school meals (OR 1.29, 95%CI 1.17–1.43) and unsatisfactory adherence (OR 1.14, 95%CI 1.05–1.23) and the “healthy” pattern, when compared with no-adherence. Moreover, a negative association was observed between high adherence to school meals and the “unhealthy” dietary pattern (OR 0.77, 95%CI 0.64–0.93) (Table 3). After adjustments, high adherence and unsatisfactory adherence remained associated with a “healthy” dietary pattern (OR 1.37, 95%CI 1.23–1.52 and OR 1.20, 95%CI 1.10–1.30, respectively) (Table 3).

DISCUSSION

In the present study, three dietary patterns (“unhealthy”, “healthy”, and “monotonous”) were identified based on markers of food intake among Brazilian adolescent students aged 13–17 years who attended public schools with school meals, based on a nationally representative school-based survey carried out in 2019. The most prevalent pattern was composed of beans, and was named “monotonous”. The “healthy” dietary pattern was positively associated with high and unsatisfactory adherence to school meals, suggesting a relationship with the frequency of adherence, that is, the consumption of school meals can contribute positively to the quality of the diet of Brazilian adolescents.

These findings can be explained both by the direct relationship between adherence to school meals, which offers healthy food groups, and by encouraging the consumption of these foods out of school based on food and nutrition education activities, which are provided by Brazilian PNAE legislation.

Models were adjusted by a question regarding purchase frequency in canteens by students. Adherence to school meals remains associated with a “healthy” dietary pattern, regardless of the influence of purchase frequency in canteens. This reinforces the importance of strengthening the PNAE as a promotion of healthy eating since the implementation and execution of norms aimed at regulating the commercialization of unhealthy foods in the school environment are considered a challenge for public schools.

In this context, it is important to highlight that the menus planned under PNAE value a diet based on fresh or minimally processed foods. It has been mandatory, since 2009, to offer a minimum of three servings of fruits and/or vegetables per week (200 g/week). The amounts of sugar, sodium, and fat in daily preparations are limited, low nutritional content drinks (soft drinks and artificial refreshments, and 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, or concentrated foods) are restricted. In addition, the legislation establishes at least 30% of the financial resources for purchasing food from family farming, which promotes healthier food in schools¹³13. Brasil. Ministério da Educação. Fundo Nacional de Desenvolvimento da Educação. Resolução CD/FNDE no 38, de 16 de julho de 2009. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar – PNAE. Brasília: Diário Oficial da União Brasil; 2009. and contributes to sustainable food systems²⁸28. Marchioni DM, Carvalho AM, Villar BS. Dietas sustentáveis e sistemas alimentares: novos desafios da nutrição em saúde pública. Rev USP 2021; 128: 61-76. https://doi.org/10.11606/issn.2316-9036.i128p61-76
https://doi.org/10.11606/issn.2316-9036.... .

In 2020, the PNAE guidelines were updated based on the dietary guidelines for the Brazilian population, which classify foods into four groups according to food processing (natural or minimally processed, processed, culinary ingredients, and ultra-processed)²⁹29. Brazil. Ministry of Health of Brazil. Secretariat of Health Care. Primary Health Care Department. Dietary guidelines for the Brazilian population [Internet]. Brasília: Ministry of Health of Brazil; 2015 [cited on Feb. 21, 2023]. Available at: https://bvsms.saude.gov.br/bvs/publicacoes/dietary_guidelines_brazilian_population.pdf
https://bvsms.saude.gov.br/bvs/publicaco... . It was established that 75% of financial resources should be allocated to the acquisition of natural or minimally processed foods, a maximum of 20% to processed and ultra-processed foods, and 5% to processed culinary ingredients. Such changes may provide better outcomes in future studies that evaluate the eating habits of schoolchildren since the purchase of ultra-processed foods under PNAE is more restricted¹²12. Brasil. Ministério da Educação. Fundo Nacional de Desenvolvimento da Educação. Resolução no 6, de 08 de maio de 2020. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar – PNAE. Brasília: Diário Oficial da União Brasil; 2020..

Other studies conducted with Brazilian adolescents who participated in previous editions of PeNSE (2012 and 2015)¹⁵15. Azeredo CM, Rezende LFM, Canella DS, Claro RM, Peres MFT, Luiz OC, et al. Food environments in schools and in the immediate vicinity are associated with unhealthy food consumption among Brazilian adolescents. Prev Med 2016; 88: 73-9. https://doi.org/10.1016/j.ypmed.2016.03.026
https://doi.org/10.1016/j.ypmed.2016.03.... ,¹⁹19. Boklis-Berer M, Rauber F, Azeredo CM, Levy RB, Louzada MLC. The adherence to school meals is associated with a lower occurrence of obesity among Brazilian adolescents. Prev Med. 2021; 150: 106709. https://doi.org/10.1016/j.ypmed.2021.106709
https://doi.org/10.1016/j.ypmed.2021.106... ,²⁰20. Locatelli NT, Canella DS, Bandoni DH. Positive influence of school meals on food consumption in Brazil. Nutrition 2018; 53: 140-4. https://doi.org/10.1016/j.nut.2018.02.011
https://doi.org/10.1016/j.nut.2018.02.01... ,²⁷27. Froelich M, Souza BSN, Andrade ACS, Rodrigues PRM, Cunha DB, Muraro AP. Adherence to school meals and co-occurrence of the healthy and unhealthy food markers among Brazilian adolescents. Cien Saude Colet 2023; 28(7): 1927-36. https://doi.org/10.1590/1413-81232023287.12462022
https://doi.org/10.1590/1413-81232023287... found an association between the consumption of school meals and healthy foods, reinforcing our findings and demonstrating the importance of the PNAE as a health-promoting policy over the years.

To our knowledge, this study is a pioneer in evaluating the association between adherence to school meals and dietary patterns in a representative sample of adolescents in Brazil. However, a study carried out by Lobo et al. in public schools in Florianópolis (SC), in the South region, presented results similar to ours¹⁶16. Lobo AS, Assis MAA, Leal DB, Borgatto AF, Vieira FK, Di Pietro PF, et al. Empirically derived dietary patterns through latent profile analysis among Brazilian children and adolescents from Southern Brazil, 2013-2015. PLoS One 2019; 14(1): e0210425. https://doi.org/10.1371/journal.pone.0210425
https://doi.org/10.1371/journal.pone.021... . The authors found that children and adolescents who reported consuming school meals were significantly more likely to have a traditional dietary pattern, characterized by a higher frequency of consumption of beans and rice. On the other hand, boys who reported not consuming school meals were more likely to have a “monotonous” dietary pattern, characterized by a higher frequency of consumption of pasta, instant noodles, and pizza/hamburger/hot dog.

The food offered by the PNAE has been associated with a lower occurrence of obesity, hypertension, and insulin resistance in adolescents¹⁹19. Boklis-Berer M, Rauber F, Azeredo CM, Levy RB, Louzada MLC. The adherence to school meals is associated with a lower occurrence of obesity among Brazilian adolescents. Prev Med. 2021; 150: 106709. https://doi.org/10.1016/j.ypmed.2021.106709
https://doi.org/10.1016/j.ypmed.2021.106... ,³⁰30. Gonçalves VS, Duarte EC, Dutra ES, Barufaldi LA, Carvalho KM. Characteristics of the school food environment associated with hypertension and obesity in Brazilian adolescents: a multilevel analysis of the Study of Cardiovascular Risks in Adolescents (ERICA). Public Health Nutr 2019; 22(14): 2625-34. https://doi.org/10.1017/S1368980019001010
https://doi.org/10.1017/S136898001900101... ,³¹31. Okamura AB, Gonçalves VSS, Carvalho KMB. School feeding as a protective factor against insulin resistance: the study of cardiovascular risks in adolescents (ERICA). Int J Environ Res Public Health 2022; 19(17): 10551. https://doi.org/10.3390/ijerph191710551
https://doi.org/10.3390/ijerph191710551... and obesity in children, which can be attributed to the impact of school meals on diet quality. These findings are consistent with our hypothesis that the food offered by the PNAE is achieving its objective of promoting the formation of healthy eating habits among students, as provided for in its guidelines¹¹11. Brasil. Ministério da Educação. Fundo Nacional de Desenvolvimento da Educação. Resolução/CD/FNDE no 26, de 17 junho de 2013. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar – PNAE. Brasília: Diário Oficial da União Brasil; 2013.

12. Brasil. Ministério da Educação. Fundo Nacional de Desenvolvimento da Educação. Resolução no 6, de 08 de maio de 2020. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar – PNAE. Brasília: Diário Oficial da União Brasil; 2020.-¹³13. Brasil. Ministério da Educação. Fundo Nacional de Desenvolvimento da Educação. Resolução CD/FNDE no 38, de 16 de julho de 2009. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar – PNAE. Brasília: Diário Oficial da União Brasil; 2009.. Therefore, the PNAE can be considered a great tool to achieve the Sustainable Development Goals for 2030, which outline strategies such as promoting healthier eating behaviors, adopting sustainable food systems³²32. Global Nutrition Report. Nourishing the SDGs [Internet]. 2017 [cited on Feb. 21, 2023]. Available at: https://globalnutritionreport.org/reports/2017-global-nutrition-report/
https://globalnutritionreport.org/report... , and mitigating the global syndemic of obesity, malnutrition, and climate change.

Although the PNAE provides free school meals and studies show positive effects of the consumption of school meals in Brazil, adherence among adolescents is still low. The school food environment, sociodemographic characteristics, and eating habits are pointed out in the literature as factors that influence the consumption of school meals. Among those factors, schools should be emphasized as an important setting to promote healthy behaviors³³33. World Health Organization. Report of the commission on ending childhood obesity [Internet]. Geneva: WHO; 2016 [cited on Feb. 21, 2023]. Available at: https://iris.who.int/bitstream/handle/10665/204176/9789241510066_eng.pdf?sequence=1
https://iris.who.int/bitstream/handle/10... . However, in the Brazilian context, the sale of competitive foods in private canteens and other places around the school contributes to low adherence to school meals and the consumption of unhealthy foods.

Some potential strengths and limitations of our analysis merit consideration. First, the PeNSE 2019 survey did not assess where food was consumed, which can be considered a limitation of this study. However, it is known that the school environment is capable of influencing consumption in other places³⁴34. Micha R, Karageorgou D, Bakogianni I, Trichia E, Whitsel LP, Story M,et al. Effectiveness of school food environment policies on children’s dietary behaviors: a systematic review and meta-analysis. PLoS One 2018; 13(3): e0194555. https://doi.org/10.1371/journal.pone.0194555
https://doi.org/10.1371/journal.pone.019... and that food consumption on school days is associated with healthier eating habits¹⁶16. Lobo AS, Assis MAA, Leal DB, Borgatto AF, Vieira FK, Di Pietro PF, et al. Empirically derived dietary patterns through latent profile analysis among Brazilian children and adolescents from Southern Brazil, 2013-2015. PLoS One 2019; 14(1): e0210425. https://doi.org/10.1371/journal.pone.0210425
https://doi.org/10.1371/journal.pone.021... . Second, the food consumption markers questionnaire from PeNSE included only a few healthy and unhealthy markers, which do not represent the adolescent’s food consumption of the whole day. Third, although the analysis of this study is based on a cross-sectional survey, the DAG was useful to identify possible confounding factors. Furthermore, we emphasize that the consistency of our results was evidenced by the dose-response relationship found between exposure and outcome. Fourth, the sample of this study should be noted since it represents Brazilian adolescents aged 13–17 years, covering the macroregions, including capitals and other municipalities. Fifth, the uniqueness of evaluating the association between adherence to school meals and dietary patterns derived by LCA in a representative sample of Brazilian school adolescents.

The results of this study show that adherence to school meals was associated with a “healthy” dietary pattern among Brazilian adolescents, which reinforces the crucial role of the PNAE in promoting health among adolescents and its potential to mitigate the global syndemic. Given the Brazilian context, in which the consumption of unhealthy foods is increasing and the consumption of healthy foods is low among adolescents, the results of this study are relevant for planning actions that encourage students to consume the food offered in schools. Furthermore, these findings should be considered by decision-makers when planning the allocation of financial resources aimed at improving eating habits among adolescents.

ACKNOWLEDGMENTS:

The authors are grateful to all students and school principals who participated in the National School Health Survey (2019), contributing to the development of this work. We are also grateful for the support of the Federal University of Mato Grosso, the Federal Institute of Mato Grosso – Campus Juína, the Coordination for the Improvement of Higher Education Personnel (CAPES), and the Brazilian National Council for Scientific and Technological Development (CNPq).

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