Artigos

INTRODUCTION


Childhood and adolescence are critical periods for health and development as it is a period of rapid physiological, sexual, neurological, and behavioral changes, besides rapid growth, which can be fully achieved with adequate nutrition 1. Eating habits, lifestyle, and behavior patterns are established during this period that may persist throughout adulthood 2. Given that children and adolescents devote a significant portion of their day within educational institutions, it is crucial to recognize the significance of this environment for promoting health and nutritional education. Specifically, the implementation of school meals has gained prominence as a vital policy with the potential to yield substantial advantages in terms of nutrition and overall well-being 3.
The availability of free school meals remains limited to a small number of countries, only 41% of children enrolled in primary school have access to a free or subsidized daily school meal, with higher rates observed in high-income countries (61%) 3. Among countries with developed economies, school meals are a common feature of national safety net programs and typically provide students with breakfast and/or lunch with a focus on improving diet quality, particularly among low-income populations4.
A previous systematic review conducted in 2020, encompassing studies from developed countries showed that free school meals are positively associated with the quality of students' diet and food security, however, when body mass index was evaluated as an outcome, the results were controversial 4 . It's worth noting that this review did not include Brazil, a country classified as upper-middle-income. In Brazil, the National School Feeding Program (PNAE) plays a crucial role since its implementation in 1979. It is objective is the formation of healthy eating habits, through food and nutrition education actions and the offer of free meals that cover the nutritional needs of all students enrolled in the public primary and secondary education network, throughout the school period5. Therefore, the PNAE stands as Brazil's longest-standing public policy for food and nutrition security, garnering international recognition with sustainable purchase initiatives, linked to the strengthening of family farming, and the broader goal of achieving Food and Nutrition Security. Moreover, it is widely acknowledged as a commendable initiative in the realm of health-focused public policies 6.
However, school-based studies with national representation have shown a low proportion of students who frequently consume the meals offered, directly reflecting on the achievement of PNAE objectives 7–9, as it is expected to directly impact the quality of students' diets, food security, and overall nutritional status, reflecting on well-being and educational development. To date, studies that have evaluated the association between the frequency of school meal consumption in Brazil and the quality of students' diet, food security, and body mass index have not been systematically evaluated. Therefore, this systematic review aimed to answer the question “Is school meals consumption associated with food consumption, food insecurity, and body mass index among Brazilian students?”.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines10. The protocol was registered with the PROSPERO International Prospective Register of Systematic Review prior to data extraction (protocol registration number: CRD42023403813)11.
Eligibility criteria
Eligible studies were quantitative studies conducted with Brazilian children and adolescents of school age (individuals aged 2 to 19 years), which evaluated the association between the consumption of school meals and diet quality, eating habits, food safety, and body mass index. The exposure was the consumption of free school meals in public schools, offered by the Brazilian School Feeding Program. The following type of articles were excluded: non-empirical articles, interventions protocol, opinions, editorials, case studies, animal studies, and abstracts of scientific events that have not been published as complete articles; study population showing any disease (e.g. diabetes, mental disorders, kidney disease, HIV, cancer, Down syndrome); studies that have included other groups beyond individuals between up to 19 years of age; and studies with school meal consumption as outcome variables. For the synteses
Data Sources and Search Strategies
We conducted an electronic search in March of 2023 of peer-reviewed literature using: MEDLINE via PubMed, Lilacs via Virtual Health Library (VHL - Biblioteca Virtual em Saúde in Portuguese), Web of Science, Embase, and Scopus, without limitations regarding language or date.
The formulated research question followed the standard PECO format: Population (P), Exposure (E), Comparison (C) and Outcome (O). For inclusion in this systematic review, articles were required to address all aspects of the PECO question. The search strategy was comprised of combinations of the following keywords (adapted for each database): Brazilian children and adolescents, school meals, school food, diet, eating habits, food insecurity, obesity, overweight, and body mass index. The full search strategies for all databases are available at Prospero protocol and Table 1. To identify additional potentially relevant studies, a search of the reference lists of these articles as well as review articles in national journals in the nutrition and public health area that were the main publisher of the papers included in the review.
Selection process
Upon completion of the search process, two independent researchers screened titles and abstracts, as well as conducted a comprehensive evaluation of the full texts. Articles with unclear eligibility were analyzed and discussed to obtain a consensus.
Quality Assessment
Assessment of study quality and biases were based on adapted Newcastle–Ottawa Scales (NOS) for cross-sectional and cohort studies, which are commonly used to assess nonrandomized research 4,12. Each study was assessed using the following criteria: selection (representative sample, sample size justified, ascertainment of exposure/risk factor, non-respondents), comparability, and outcome (assessment of outcome, statistical test). In assessing the representativeness of the sample, studies received one point if their sample was deemed representative of the target population. Those providing justification, satisfactory sample sizes, or a minimum of 100 participants earned one point on the scale. Two points were allocated to studies employing objective exposure assessment, particularly those evaluating the weekly frequency of school meal consumption in this review. Concerning non-respondents, one point was assigned to studies presenting the proportion of the target population recruited, meeting pre-specified targets, or providing a basic summary of non-respondent characteristics in the sampling frame. Studies controlling for confounding factors received two points for applying analyses or adjustments concerning relevant predictors, risk factors, or confounders. In terms of outcome assessment, two points were granted to studies using objective measures, while one point was given to studies employing validated non-objective measures. Finally, for statistical tests, one point was awarded to studies clearly describing the appropriate statistical tests used for data analysis, with included measures of association featuring confidence intervals and/or probability levels.
Quality assessments were interpreted based on the following categories: very high risk of bias (0–3 points), high risk of bias (4–6 points), and low risk of bias (?7 points).
Synthesis methods
A narrative (descriptive) synthesis grouping by the outcome the PRISMA protocol 10 and Synthesis without meta-analysis (SWiM) reporting guideline 13. The synthesis encompassed details such as location, participant characteristics, study design, and year. It also provided insights into the school meal measure (whether consumption regardless of frequency or the weekly frequency and cutoffs), the method used for assessing the outcome measure, the proportion of school meal consumption by students, and findings regarding the association between exposure and outcome. Due to the heterogeneity of the exposure and outcome measures across the studies included, it was not feasible to merge the data for a reanalysis through meta-analyses, owing to the substantial heterogeneity.

RESULTS

The initial search of the five databases identified a total of 451 articles. After removing duplicates, 240 articles remained. The primary screening excluded 197 records. The full text of the remaining 43 publications were assessed in detail, and 21 articles were excluded. The primary reasons for exclusion in this step concerned: 1) the study exposure evaluation (i.e., did not assess consumption of school meals), 2) did not assess the outcomes of this review, 3) did not match the aim of the review (no association between exposure and outcome of the interest), and 4) the population included in the study (did not specifically analyze Brazilian or public-school students, including studies in other countries or multicentric). Four additional articles were identified from references or publications citing the referent literature. Therefore, a total of 26 articles were included in this review (Figure 1).
Quality scores for the included articles ranged from 5 (high risk of bias) to 10 (low risk of bias). Three of the included studies were classified as having a high risk of bias. All studies presented objective outcome measures, two (7.7%) did not describe appropriate statistical tests used for data analysis. Information about non-responses was the criterion with the highest number of studies that did not meet (n= 10, 38.5%), followed by sample representativeness (n= 8, 30.7%), and comparability of subjects or confounding factors controlled (n= 7, 26.7%) (Table 2).
Most studies had BMI/nutritional status (n=12) 8,14–24 and diet or eating habits (n=12)25–36 as outcomes. Two studies evaluated the association between school meal consumption and food insecurity (n=2) 37,38 and one 24 evaluated both nutritional status and food consumption as outcomes (Table 3). The 26 studies included in this review were published between 2005 and 2023, 18 (69.2%) were written in the English language and 8 (30.8%) only in Portuguese, with 10 studies of national representativeness, 8,15,17,24,25,27–29,32,33. One study was carried out in 10 municipalities in the country, two studies used data from each Brazilian region, although, without sample representativeness 23, 7 studies were conducted in the Southeast region 18,22,26,30,34,37,38, 5 in the south region 16,19,31,35,36 and 3 in the northeast region of the country 14,20,21. Most of the studies were cross-sectional (n=23), 2 had a longitudinal design 14,20, and 1 case-control study 18. Studies showed wide variation in sample size (range?=?73 to 86,660 children/adolescents).
Among studies with national representativeness, five were carried out with the 2015 National Survey of School Health (PeNSE), three with the 2012 PeNSE, one with the Study of Cardiovascular Risks in Adolescents (ERICA), and another one with the Brazilian Household Budget Survey (HBS) of 2008-2009. The evaluation of the consumption of school meals varied between studies, being evaluated the consumption or not, regardless of the frequency 8,14,15,18,35,36,38, consumption on the previous day 31, meaning of one or more school meals consumption at three R24h 34, or the weekly frequency reported by the student. In the latter case, the classification of consumption as regular, satisfactory, or strong/effective/high adherence, varied from three or more times a week 20,24,28,30,32,33,37, to four or five times a week 16,19,23, to daily consumption (5 times a week) 17,22,27,29.
Among the studies that considered the consumption of school meals, regardless of the weekly frequency, the consumption was reported by more than 80% of the students (between 82% and 95.7%), except for Gonçalves et al. 8 that observed 52% of school meal consumption. When considering regular consumption as 3 or more times a week, the prevalence of school meal consumption varied from 22.8% to 76.2% 24,28,30,32,33,37. Consumption for 4 to 5 days varied from 23.7% to 57.0% 16,19,23 The daily consumption (or 5 days per week) varied from 21.0% to 26.7% 17,22,27,29. De Medeiros et al. 20 and Azeredo et al. 39 did not show the results for the proportion of students that of school meal consumption.
The reference curve of the World Health Organization for the classification of BMI-for-age Z-score was adopted in almost all studies, except for Bleil et al.16, Rodrigues et al.22 and Sturion et al.23 who adopt the NCHS/CDC from the general United States population (National Center for Health Statistics; Centers for Disease Control and Prevention) curves because their studies were developed before the publication of WHO curves, with a multicenter Growth Reference study. Half of the studies considered the assessment of BMI-for-age 14,15,17,20,21,23 or weigh-for-age Z-score/percentile 20 as a continuous variable in the analyses, and three also classified overweight or obesity 14,15,17.
Two cross-sectional studies analyzing the nutritional status as a continuous variable and controlling for confounding factors, observed that students who consumed school meals had lower BMI for age and less prevalence of overweight and obesity compared with those who did not consume 15,17. On the other hand, Sturion et al. 23 verified a positive association between BMI for age and consumption of school meals, and de Medeiros et al. 20 also observed a greater increase in weight-for-age in two years of follow-up among children who consumed school meals, but the authors did not control for confounders. All six studies that considered overweight and/or obesity as outcome did not find significant associations with the consumption of school meals 8,16,18,19,22,24.
When analyzing diet quality or eating behaviors as outcome, most studies considered the weekly frequency of consumption of healthy and unhealthy food groups 24,32,39, consumption frequency as scores or co-occurrence of regular consumption considering the evaluated food groups 27,29, or dietary pattern 31. Among the studies that considered food consumption based on a 24-hour recall, Bento et al. 26 evaluated the participation of the NOVA classification groups, Horta et al. 30 evaluated macro and micronutrients, Prado et al. 34 calculated Healthy Eating Index (HEI) adapted for Brazil, and Rossi et al. 35 considered food groups in their assessment. Two studies evaluated breakfast consumption 28,32, and Locatelli et al.32, also evaluated the consumption of meals with parents or guardians.
Two studies conducted in the Southern region of Brazil found no association between school meal consumption and dietary quality [32, 34]. All studies carried out with nationally representative data found a positive association between the consumption of school meals and the consumption of healthy food groups, including a dose-response relationship 25,26. Positive results were also observed in studies that the diet quality was assessed through scores 26,27. However, Horta et al. 30 observed that besides the higher consumption of Vitamin C, fruits, and vegetables, adolescents from high social vulnerability risk areas who reported consumption of school meals in 3 or more times per week had a higher mean of ultra-processed foods consumption (especially beverages). All studies examining diet and eating habits had a low risk of bias.
Barros et al.38 and de Amorim et al.40 adopted the Brazilian Food Insecurity Scale (BFIS) to classify households’ food (in)security, but the first classified the families as food security or food insecurity (FI), and the last classified in three categories (food security, mild FI, moderate/severe FI). Barros et al. 38 did not find a significant difference in the prevalence of food insecurity among students who consumed or did not consume school meals. Nonetheless, de Amorim et al. 37 considered the frequency of school meal consumption in three categories (does not consume, from 1 to 2 times per week, and from 3 to 5 times per week) and found that households with moderate or severe FI were more likely to have a student who consumed regular school meals (3 to 5 times per week), even after adjusting for sociodemographic variables.


DISCUSSION


It was observed a crescent number of studies in the last two decades that evaluated the association of school meal consumption in Brazil with nutritional status, diet, and food insecurity. Evidence concerning the effect of school meal consumption on the BMI and weight status remains unclear, since two studies found a positive association with BMI or weight for age and another two showed a negative association with BMI for age and prevalence of obesity. However, the majority of the studies showed a positive association of the consumption of school meals with healthy food consumption or diet quality and was associated with lower consumption of unhealthy food among children and adolescents. Food security was only evaluated by two studies, and both verified the positive relationship between food consumption and the situation of food insecurity. The results indicate that school meals contribute to a healthier diet among students and serve children from vulnerable families.
The studies evaluated in this systematic review showed consistent results that students who consume school meals have better diet quality, with greater consumption of foods considered healthy such as fruits and vegetables and lower consumption of ultra-processed foods. These results can be attributed to the requirements of the PNAE that establish the recommendations on prioritization of in natura food and about macronutrients and micronutrients recommendations, the restriction of ultra-processed foods rich in sodium or saturated fats, and also the use of at least 30% of the resource transferred by the National Education Development Fund (Fundo Nacional de Desenvolvimento da Educação (FNDE), an agency linked to the Ministry of Education) for the purchase of food from family farming 5. This requirement might reduce the student’s consumption of processed and ultra-processed foods in school meals and encourage the consumption of fresh or minimally processed foods, which is prioritized by the Dietary Guidelines for the Brazilian population41.
In a previous study that evaluated the degree of food processing obtained through the PNAE in three municipalities in southern Brazil, it was observed that more than half of the calories of the total energy purchased came from natural and minimally processed foods 42. However, Araújo et al. 43 observed that between 2011 and 2017, only one-third of the Brazilian capitals met the established target proportion of the purchase of food from family farming. These results emphasize the importance of promoting family farming, implementing effective monitoring measures to ensure the support of local production, and adapting menus to regional production and culture. These actions are consistent with the social commitment and nutritional component of the PNAE.
According to the PNAE, recommendations for students in basic education, recommendations should be 20% of nutritional requirements for one meal and 30% for two or more meals 44. However, most of the studies systematically reviewed by da Silva et al. 45 showed the inadequacy of macronutrients (proteins, carbohydrates, and lipids) and micronutrients (vitamins A and C, calcium, iron, and sodium) in the school menus. This result could be explained by the not adequate allocation of resources for the purchase of family farming, as mentioned before, and higher purchase of ultra-processed foods, as evidence shows that these ultra-processed foods are negatively associated with the consumption of micronutrients such as iron, zinc, and fiber 46. However, the new the rule for the planning of school menus, which restricts even more the purchases of ultra-processed foods 5, may change that scenario.
In light of the nutritional inadequacies observed, there is a highlighted need for more rigorous monitoring of the nutritional quality of school meals. Responsible institutions, such as FNDE, should ensure compliance with the nutritional recommendations established by PNAE. The low compliance with nutritional recommendations underscores the necessity to intensify nutritional education activities in the school environment. The integration of educational programs promoting healthy food choices can complement efforts to enhance students' dietary quality. Given the challenge of reaching all students, especially those reporting low school meal consumption frequency, specific strategies need to be developed. Understanding socioeconomic factors, student perceptions, and the school environment can inform effective approaches to increase adherence.
In the present review, only one study30 considered the average daily consumption of micronutrients, in addition to food groups. The usual nutrient and food intakes (i.e., after correcting the distribution for within-person variance) among children of 8 to 12 years old from public schools in Belo Horizonte (Minas Gerais), regarding the consumption of school meals, stratified by social vulnerability risk. When comparing food and nutrient intakes of children who reported not consuming school meals regularly and living in low/medium v. those high/very high social vulnerability risk areas, it was observed a lower mean intake was observed for almost all protective nutrients and food groups and higher mean intake for harmful nutrients and food groups among children from socio-economic disadvantaged regions presented. This was expected since socio-economic condition is one of the most important determinants of food intake 47. However, mean intakes of foods and nutrients are very similar comparing food and nutrient intakes of children living in low/ medium v. high/very high social vulnerability risk areas who reported consuming school meals regularly. In simple terms, the study indicates that the consumption of school meals alleviated dietary discrepancies related to social inequalities and PNAE has an important role in combating nutritional deficiencies related to social deprivation.
In this context, the discrepant BMI results of the studies in this systematic review should be analyzed together with the few studies with food insecurity as an outcome. It should be considered that since its implementation, the PNAE has made important advances that have contributed to the consolidation of the objectives of the National Food and Nutrition Security Policy (PNSAN) in Brazil, promoting Food and Nutrition Security and guaranteeing the Human Right to Adequate Food (DHAA), through a universal service. It is recognized that school meal public programs, through the provision of high-quality food, have the potential to mitigate the dual burden of under and overnutrition, which are co-existing conditions in LIMCs 48,49.
Similar to the results verified in this systematic review, previous review 4 evaluating studies on universal free school meals carried out in high-income countries highlighted that there were few studies that evaluated BMI as an outcome. However, among the limited number of studies considered to have a low risk of bias, 2 out of 3 found universal free school meals were associated with lower BMIs among students. In the present review, of the 10 studies considered to be at low risk of bias, only 3 observed a significant association.
In this review, two studies analyzed found a positive association between BMI for age and consumption of school meals, it is important to highlight that one analyzed data from 1997 23, in which the PNAE had a more welfare profile in the context of expressive undernutrition prevalence among children 50, and that another 20 verified the increase in three years of follow-up in a longitudinal study with a convenience sample and high risk of bias. However, both studies that found that school meal consumption was associated with lower BMI for age or prevalence of obesity were carried out from a nationally representative sample in the last 15 years, analyzing children under 10 years of age15 and adolescents between 11 and 19 years of age 17. Bandoni et al. 15 did not consider the frequency of consumption of school meals, but the origin of the food (taken from home, offered by the school, or bought at the canteen), on the other hand, Boklis et al. 17 considered the frequency of consumption as null zero/week), Low (1 to 2x/w), moderate (3 to 4x/w), or high (5x/w) and the authors highlighted the dose-response relationship in the association between the indicators of obesity and the frequency of consumption of school meals.
The PNAE regulations regarding the quality of food offered and the results observed in Brazilian studies that show the inadequacy of snacks brought from home 35,36 or available food outlets inside or around schools 25,51, are among the hypotheses about the consumption of school meals in PNAE may reduce the risk of obesity to the extent that they replace less nutritionally balanced foods with higher quality school meals. Furthermore, nutritional education activities could impact on the improvement of the quality of students' diets in addition to the food consumed during school hours52. The nutritional education activities are requirements by PNAE 5 but the lack those were pointed out by Rocha et al.53.
Although the PNAE has advanced in the last years and is universal to all students from public schools 6, the challenge of reaching all students remains. About one-quarter of students reported daily intake of school meals in the studies that consider the frequency of consumption. Among the factors associated with adherence to school meals there are socioeconomic conditions, adolescents’ perception about school meal healthfulness and cafeteria ambiance, and the availability of other types of food inside and nearby schools 54,55. Based on a systematic review, Cohen et al. 56 highlighted seven strategies to increase the consumption of school meals, including adapting recipes to improve the palatability and/or cultural appropriateness of foods, enabling students to have sufficient time to eat, having recess before lunch, and limiting students’ access to competitive foods during the school day.
Among the limitations of this study, the assessment of outcomes varied from one study to another, especially regarding the evaluations of diets of children and adolescents. While these methods have typically been validated, due to the heterogeneity in outcome measures, a meta-analysis was not possible. Furthermore, six out of 26 studies were developed before 2009 15,16,22,23,35,38, when PNAE was universalized for all basic education (primary and secondary education) and guided by some principles such as equity, social participation, universality, sustainability, continuity, sharing of responsibilities, and human right to adequate food and respect for regional habits and traditions. With the law, the program was extended to the entire public education network 44.
Regarding exposure assessment, the evaluation of consumption frequency revealed significant variability. While most studies utilized the student-reported weekly frequency, the classification of consumption as regular, satisfactory, or strong/effective/high adherence exhibited considerable diversity. This diversity posed a challenge in systematizing the study results. Moreover, studies utilizing the national database from PENSE also faced variability, with the 2015 edition featuring two samples of different representativeness. This divergence was associated with distinct estimations of school meal consumption.
Studies about the frequency of consumption of school meals are still relevant to comprehensively address the challenges surrounding low student participation in school meals. It is crucial to explore specific barriers, including socioeconomic factors, individual perceptions, and characteristics of the school environment. A deeper understanding of these factors can inform strategies aimed at increasing participation. Additionally, conducting studies to assess the impact of nutritional education activities within the school environment, particularly those linked to the PNAE, is essential. This involves investigating how these activities influence not only students' knowledge but also their food choices and long-term habits. Furthermore, a more in-depth analysis of PNAE practices across different regions of Brazil, considering cultural and socioeconomic differences, may reveal regional patterns and guide strategies tailored to each locality's specific needs.
In 2020, new regulations brought the PNAE procurement guidelines closer to the Dietary Guidelines for the Brazilian Population, the regulations state that a minimum of 75% of school meal funds must be spent on unprocessed or minimally processed foods, a maximum of 20% on processed foods (preferably not UPF), and up to 5% on culinary ingredients, such as salt, oil, and sugar 57. Therefore, new studies should be developed to evaluate the impact of school meals under this new regulation on the outcomes of diet quality and obesity indicators.
Examining the role of the school community, including parents, teachers, and administrators, in promoting healthy food choices among students is another crucial aspect. Understanding how community involvement affects the effectiveness of school nutrition policies can be pivotal. Comparing various PNAE implementation models in schools, considering variations in dietary practices, nutritional quality of meals, and impacts on students' health, can provide insights into the most effective approaches.
Investigating the long-term effects of regular school meal consumption on students' health, encompassing not only obesity indicators but also nutrition-related conditions, is paramount. Additionally, conducting international comparative studies to contextualize PNAE practices concerning to school feeding programs in other countries can offer insights into best practices and effective strategies. This holistic approach aims to contribute to the development of informed and tailored interventions to enhance the overall impact of school nutrition programs in Brazil.
Only three studies were classified as high risk of bias by NOS scores, but It is worth noting that publication bias, where studies yielding non-significant outcomes are less likely to be published, could have been a concern. Nevertheless, several studies included in the review discovered no significant associations, mitigating this potential issue.

CONCLUSION

The present systematic review has provided a comprehensive critical analysis of the studies that evaluated school meals consumption in Brazil considering the association with nutritional status, diet, and food insecurity. We systematically searched the literature in five electronic reference databases and quality assessments. Evidence concerning the effect of school meal consumption on the BMI and weight status remains unclear, but it shows to be associated with higher healthy foods consumption and was associated with lower consumption of unhealthy foods. The limited studies examining food security also suggested that universal free school meals are serving children from families in vulnerable situations.
Consistent findings indicating a positive association between school meal consumption and a healthy diet suggest that PNAE plays a crucial role in promoting student health. It is recommended to reinforce strategies prioritizing whole and minimally processed foods, aligning with PNAE guidelines. Given the cultural and regional diversity of Brazil, PNAE implementation should be adapted to reflect the specificities of each locality. This includes promoting support for local production, respecting regional culinary traditions, and ensuring menus align with cultural preferences.

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