Consuming school meals improves Brazilian children’s diets according to their social vulnerability risk

Household food insecurity and its association with diet quality in high-risk children

The aim of this study was to evaluate the association between dietary practices and household food insecurity (HFI) status among high-risk children during the COVID-19 pandemic. This cross-sectional study was conducted with 147 children aged 1 to 9 attending at three reference health centers in the city of Rio de Janeiro. Diet quality data was assessed using Healthy Eating Indices. The Brazilian Scale of Food and Nutrition Insecurity measured HFI status. Associations between HFI and dietary practices were assessed using logistic regression models. Almost half of the children lived with food insecurity (47.6%). HFI was associated with deteriorated diet quality, evidenced by the increased weekly frequency of consumption of ultra-processed foods (UPF), such as sugar-sweetened beverages and processed meats, and reduced frequency of fruits and vegetables. Parents perceived a reduction in meat and milk consumption and an increase in the intake of UPF among households of children in HFI throughout the pandemic. Our results suggest that HFI status was associated with deterioration in diet quality during the critical phase of social isolation.

Healthy dietary patterns linked to Brazilian adolescents' school meal adherence

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.

Arsenic, Cadmium, and Lead Levels in School Meals and Their Risk Assessment in Municipalities in Bahia, Brazil

BACKGROUND

School meals represent a significant supply of nutrients for children in Brazil, especially those in conditions of social vulnerability.

OBJECTIVES

This study aimed to assess the levels of arsenic (As), cadmium (Cd), and lead (Pb) in meals served in public elementary schools in four municipalities in the state of Bahia, Brazil, and assess the risk posed to children's health.

METHODS

Ninety-six samples were collected from 16 schools, freeze-dried, and subjected to microwave-assisted digestion. The As, Cd, and Pb levels were determined by graphite furnace atomic absorption spectrometry. The risk assessment was based on calculating each element's hazard quotient (HQ).

RESULTS

None of the samples reached or exceeded the tolerable levels for the elements analyzed. Pb was the metal that obtained the most significant result, reaching maximum levels of 39-157 µg·kg-1.

CONCLUSIONS

No element exceeded the PTWI proposed by JECFA; thus, the toxic metal content in school meals poses a negligible risk to children's health.

A choice architecture intervention targeting school meals and water frequency intake: A school-based randomized trial

Our aim was to evaluate the impact of choice architecture on school meals and water intake frequency. We conducted a school-based randomized trial in seven elementary municipal public schools (control = 3; intervention = 4) in Rio de Janeiro, Brazil. The interventions group received the following modifications: (1) banner of the daily school meal menu and two superheroes, (2) waterproof tablecloths, (3) posters on healthy eating habits, (4) displays with playful names, (5) new containers for fruits, and (6) colored footprints for one month. Changes in school meals and daily water frequency consumption were evaluated through intention-to-treat analyses, using generalized estimating equations models for repeated measures, considering the classes' cluster effect. Data from 974 students in the fifth and sixth elementary school grades were analyzed (control = 356; intervention = 618). At baseline, 47.1% of students were female, with a mean age of 12 years (SD = 1.4), 39.2% reported daily consumption of school meals, and 45.7% consumed water from the school drinking fountain three or more times a day. We observed an increase in the odds of daily water intake in the intervention group compared to the control (OR = 1.4 95% CI = 1.1-1.9), no changes in the school meals (OR = 1.2 95% CI = 0.9; 1.6). Low-complexity strategies based on choice architecture applied in the school environment can be promising in increasing water intake frequency among elementary students in public schools. TRIAL REGISTRATION: This study was registered on the Clinicaltrials.gov platform under the number NCT03136016. Access: https://clinicaltrials.gov/ct2/show/NCT03136016.

Adherence to school meals and co-occurrence of the healthy and unhealthy food markers among Brazilian adolescents

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.

The effect of school-entry age on health is understudied in low- and middle-income countries: A scoping review and future directions for research

Background

Substantive literature has assessed the impact of starting school at younger ages relative to peers on health in high-income countries (HICs), but there is little evidence from low- and middle-income countries (LMICs). Conclusions drawn from HICs may not apply to different education contexts and health threats. This study maps the empirical evidence on the effect of school-entry age on health in LMICs and identifies directions for future research.

Methods

We conducted a scoping review between August and September 2022 by systematically searching the health sciences, education, economics, psychology, and general sciences literature and included quantitative and qualitative studies. The exposure of interest was relative age for grade defined as starting or progressing through school at a younger or older age compared to peers who are in the same grade. We extracted key characteristics of included studies and summarized their findings. We categorized results into broad health domains which emerged a posteriori from our analyses of included studies, including neurodevelopment and mental health, sexual and reproductive health, non-communicable diseases, and nutrition.

Findings

We identified 8 studies from middle-income countries published between 2017 and 2022. Among those studies, we identified 3 quasi-experimental studies using data from Brazil, Mexico, and Vietnam, and 5 observational studies primarily from Türkiye. Children starting school earlier had an increased risk of being diagnosed with attention deficit hyperactivity disorder, earlier sexual debut and cohabitation, adolescent pregnancy, adolescent marriage, and engaged more frequently in risky behavior compared to children who started school later. Pregnant women who started school younger also had fewer prenatal care visits and experienced more pregnancy complications. Although most studies identified negative health consequences from starting school earlier, the evidence for nutritional outcomes, such as overweight and stunting, was mixed. No studies were identified from low-income countries.

Conclusions

Little is known about the health consequences of school-entry age in low-resource settings. Additional research is needed to investigate the impact of relative age for grade, whether and how these effects persist into adulthood, and to inform strategies that can offset potential disadvantages stemming from school-entry cut-off dates.

Perceptions of Health Needs among Venezuelan Women Crossing the Border in Northern Chile during the COVID-19 Pandemic

In parallel to the COVID-19 pandemic, Chile has experienced a significant influx of international migrants, many of whom are Venezuelan women who have entered the country through unauthorized crossing points. In this context, gender and migration intersect as the social determinants of health, leading to their experiencing a range of adverse events. This poses important challenges in terms of short- and long-term health outcomes, the social determinants of health, and access to healthcare. This study aims at describing Venezuelan women's perceptions of their health needs as they migrate to Chile via an unauthorized crossing point, with a focus on adverse events throughout the migration cycle, self-reported health needs, and responses. A qualitative case study was carried out with 22 participants in the Antofagasta region of Chile, including Venezuelan migrant women, healthcare professionals, and social workers from the public healthcare system, stakeholders from non-governmental and international organizations, and local government officials. The semi-structured, individual interviews were analyzed thematically. The results show that Venezuelan women face a range of adverse events throughout the migration cycle. The perceived health needs that are reported are sometimes linked to these adverse events or existed prior to migration and were exacerbated throughout the migratory cycle. Addressing these physical and mental health needs is essential for short- and long-term individual and public health; however, despite substantial efforts to ameliorate the situation, persisting gaps in access to care are reported.

Awareness of and Participation in School Food Programs in Youth from Six Countries

BACKGROUND

School-based meal programs can promote healthy dietary intake in youth. However, limited data exist regarding the impact of income-targeted school meal programs across countries, particularly among food-insecure youth.

OBJECTIVES

We examined self-reported awareness of and participation in free school meal programs, and associations with dietary intake in youth from 6 countries with differing national school meal policies.

METHODS

Data were collected through the 2019 International Food Policy Study Youth Survey, a cross-sectional survey of 10,565 youth aged 10-17 y from Australia, Canada, Chile, Mexico, the United Kingdom, and the United States. Regression models examined: 1) country differences in awareness of and participation in breakfast and lunch programs; and 2) associations between lunch program participation and intake of fruit and vegetables, and "less healthy" foods during the previous school lunch day.

RESULTS

Awareness of and participation in free breakfast and lunch programs varied across countries. Approximately half of USA and Chilean students participated in school lunch programs-the countries with the most comprehensive national policies-compared with one-fifth of students in the United Kingdom, and ∼5% in Australia, Canada, and Mexico (P < 0.001 for all contrasts). In the United States and Chile, more than two-thirds of youth with the highest level of food insecurity participated in lunch programs, compared with 45% in the United Kingdom, 27% in Canada, and ≤20% in Australia and Mexico. In all countries, youth reporting school lunch program participation were more likely to report fruit and vegetable intake during their previous school lunch (P < 0.001), and higher intake of "less healthy" food in all countries except the United States and Chile.

CONCLUSIONS

More comprehensive national policies were associated with greater participation in school meal programs, particularly among youth at greatest risk of food insecurity, as well as healthier dietary intake from school lunches.

School starting age and nutritional outcomes: Evidence from Brazil

Recent studies reported that the age of primary school enrolment is a major driver of educational achievement and adult income, but its impacts on childhood health and nutrition remain largely unknown, particularly in developing countries where childhood stunting and overweight coexist. In Brazil, children are supposed to enrol in primary school the year they turn 6. Using a database of middle school students in Brazil based on a 2015 survey, I implemented an instrumental variables strategy using quasi-exogenous variations in the students' birthdates to isolate the impact of late primary school enrolment (i.e., older than 6 when enrolled) on height-for-age and body mass-for-age indicators. Overall, late enrolment has protective effects against hazardous weight gain (-0.14 z-score unit) but significantly increases the risk of moderate stunting (by 1.5% points). Heterogeneity in family backgrounds may explain these results. Indeed, delayed school enrolment is particularly detrimental for the nutritional status of students from underprivileged settings. In terms of public policy, rather than changing school starting age, this study highlights the importance of focusing on pathways to fight both stunting and overweight conditions in Brazilian children.

School meals consumption is associated with a better diet quality of Brazilian adolescents: results from the PeNSE 2015 survey

OBJECTIVE

To assess the association between the consumption of school meals offered by the National School Feeding Program (PNAE, in the Portuguese acronym) and the diet quality of adolescents aged 11 to 19 years from Brazilian public schools.

DESIGN

Cross-sectional.

SETTING

Public schools in Brazil.

PARTICIPANTS

A sample of 12 260 adolescents aged 11 to 19 years from 2015 National School Health Survey. High consumption of PNAE school meals were considered when the adolescents consumed school meals 5 d/week. Food consumption data were obtained from a 7-d FFQ and converted into three diet quality assessment scores, namely (1) consumption of healthy foods; (2) consumption of unhealthy foods and (3) overall diet quality. Crude and adjusted linear regression models were used to test the association between high consumption to school meals (daily consumption) and each diet quality score.

RESULTS

More than one-fifth of the adolescents (21·5 %) reported high consumption of school meals. High consumption of school meals was directly associated with the score of the overall diet quality (adjusted coefficient = 0·18; 95 % CI 0·07, 0·30) and healthy food consumption (adjusted coefficient = 0·42; 95 % CI 0·26, 0·57), and inversely associated with the unhealthy food consumption score (adjusted coefficient = -0·23; 95 % CI -0·35, -0·10).

CONCLUSION

Our results showed that the consumption of PNAE meals may contribute to healthy eating promotion in Brazil.

Low adherence to traditional dietary pattern and food preferences of low-income preschool children with food neophobia

OBJECTIVE

To associate dietary patterns and food neophobia in low-income preschoolers.

DESIGN

This was a cross-sectional study using a semi-structured questionnaire for socio-demographic data, birth conditions and breast-feeding history. Food neophobia was assessed using an adapted version of the Child Food Neophobia Scale. Children's nutritional status was assessed using BMI-for-age and height-for-age Z-scores. Dietary patterns were estimated using a semi-quantitative FFQ through exploratory factor analysis. Multiple linear regression was used to test for an association between food neophobia and dietary pattern adherence.

SETTING

Philanthropic childhood education schools in Aracaju, an urban community in northeastern Brazil, between July and December 2017.

PARTICIPANTS

Two hundred fourteen children aged 3-6 years and their parents.

RESULTS

The percentages of low/medium and high food neophobia among preschoolers were 85·9 % and 11·2 %, respectively. Children with high food neophobia more frequently consumed ultra-processed foods rich in sugars (snacks, filled and unfilled cookies and sweets), as well as protein-rich foods (white meat, cheese and yogurt). Three dietary patterns were identified (traditional, snacks and school snacks). Children with a high level of neophobia had lower adherence to traditional dietary patterns.

CONCLUSIONS

A high level of food neophobia among socially vulnerable preschoolers is an eating behaviour related to unhealthy eating and is associated with the poorest diet in typical foods.

Criteria adopted for school menu planning within the framework of the Brazilian School Feeding Program

ABSATRCT Objective This study aimed to investigate the main criteria used by nutritionists to plan school menus within the framework of the Brazilian National School Feeding Program. Methods Nutritionists from 21 municipalities in Southern Brazil were interviewed. Municipalities had between 20,000 and 70,000 inhabitants and were located in different mesoregions. Data were collected using an open-ended questionnaire and subjected to content analysis using NVivo® software. Results Sixteen criteria were identified, grouped into four categories: (1) food habits, culture, and acceptance; (2) nutritional characteristics; (3) food availability; and (4) management and execution. Brazilian National School Feeding Program regulations were recurrently cited within all identified categories, which demonstrates the influence of the program on nutritionists’ activities. Conclusion Brazilian National School Feeding Program regulatory guidelines for the development of school menus seem to influence the decision making of nutritionists. However, food purchase from family farms and calculation of meal nutritional value seem to be incipient criteria.

Papass clinical trial protocol: a multi-component school-based intervention study to increase acceptance and adherence to school feeding

Background

One of the largest school feeding programs in the world is the National School Feeding Program of Brazil. However, results from the 2012 National School Health Survey indicated that only 22.8% of 9th grade students in Brazilian public school system consumed school meals. The literature presents few studies aiming to promote healthy food consumption in the school environment from interventions, which found inconclusive results. Thus, this study aims to present a protocol to evaluate the effectiveness of multi-component school-level interventions to increase adherence and acceptance to school feeding.

Methods

School-based multi-component clinical trial with students from 4th-9^h grade from 3 municipal schools of Sumidouro, Rio de Janeiro, Brazil, in 2019. The study design will be parallel, with 3 arms: Control group (without intervention); Intervention group 1 (changes in school environment) and Intervention group 2 (changes in menu and school environment). Interventions in the environment will be based on the principles of choices architecture and, the modification in the dishes that make up the menus offered to the students, on the factors that contribute to poor adherence and acceptance to school feeding, identified by focus groups. Adherence to school feeding will be assessed through a specific question in the questionnaire directed to the frequency of consuming school meals in the week, applied by researchers in three moments. Acceptance will be assessed from the acceptability test application with dishes served to students during the year. Statistical analyses will be performed using generalized linear models, which will be used to assess the impact of the intervention, and will include 3 main variables: intervention, time and the intervention x time interaction.

Discussion

This study will investigate if the impact of the implementation of interventions in the environment and in the dishes served to students may increase adherence and acceptance to school feeding. Positive results could show the effect of implementing interventions throughout Sumidouro’s public school system, as well as throughout the country, aiming to improve the consumption of school meals.

Trial registration

Brazilian Registry of Clinical Trials, RBR-7mf794. Date of registration: December 27, 2018.