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PROMOTING AND COMPETING FACTORS OF ADEQUATE AND HEALTHY FOOD IN THE SCHOOL FOOD ENVIRONMENT

Patrícia Henriques, Camile Robady Torres de Alvarenga, Geíza de Vasconcellos de Almeida, Daniele da Silva Bastos Soares, Patrícia Camacho Dias, Roseane Moreira Sampaio Barbosa, Silvia Eliza Almeida Pereira de Freitas, Daniele Mendonça Ferreira.

ABSTRACT
This study aimed to characterize and evaluate the food environment of public schools regarding identified healthy eating competing and promoting factors. A quantitative descriptive and observational study was conducted in 14 public schools in a municipality in Rio de Janeiro and their surrounding areas. Photographic records and field diaries were adopted for this purpose. Food-related murals, vegetable gardens, school cafeterias, and teachers sitting along during meals were considered components that promote a healthy food environment. Competing components were snacks brought by students, canteens, informal food sale and packaging, and ultra-processed foods circulating in schools. A 500-meter radius from the school gate was considered to characterize outlets in the school surroundings. The foods sold were categorized per the NOVA classification. The study identified a predominance of healthy eating-promoting factors against competing factors. However, we identified available ultra-processed foods inside schools, and their availability prevailed in the school’s surrounding areas. The competing factors identified in the study may contribute to low adherence to school meals.
Keywords: school meals; ultra-processed foods; food social space.

INTRODUCTION
The food environment is characterized by physical, economic, political, and sociocultural aspects determining opportunities or barriers to adopting a healthy diet1. The organizational food environment refers to where food is sold or supplied to members of institutions and organizations, such as schools, hospitals, and universities2,3.
In the school space, the food environment comprises all logistics involving food availability in and around the school where food is found, obtained, purchased, or consumed, and the nutritional content of these foods. It also includes all available information (brands, advertising, labeling, and packaging), promotion and price of food, and food products4.
In Brazilian public schools, food is regulated by the National School Feeding Program (PNAE), which provides meals based on fresh and minimally processed foods to meet the nutritional demands of students and contribute to adequate growth and development, school performance and education, and healthy eating practices5. However, some factors in the food environment can adversely influence students’ food choices, such as purchasing and consuming food in canteens or cafeterias, snacks taken from home, which are not always healthy, and the sale of food in the school environment6-9. Such factors compete with the food offered in schools by the PNAE, compromising adherence, favoring weight gain, and establishing inadequate eating habits10-12.
From another perspective, research indicates that schools that adopt a whole-school approach are more successful in adhering to school food standards. This approach refers to strategies that involve the entire school in promoting healthy eating habits, including offering healthy foods at school and food education13, creating a positive food culture, and involving parents and the community14.
Evidence about the influence of the school food environment on students’ health, especially the development of overweight and obesity, has been revealed from the analysis of the available food outlets around schools15 and the provision or permission of food within schools16.
The obesogenic environment has been defined as the sum of the influences of the environment, opportunities, or living conditions on promoting obesity in individuals or populations, evidencing the relevant relationship between the environment and health outcomes17. In this context, studies on the food environment are essential to recognize its potential as a promoter or obstacle to a healthier life. Recently, a study evaluated the barriers and facilitators for promoting healthy eating in the consumer’s food environment18. However, studies on the school food environment conducted in Brazil were limited to evaluating the environment or comparing public and private schools9,19,20. Therefore, a gap in the literature regarding the barriers and facilitators in the school environment that can promote or compromise the food offered within the PNAE has been identified. Thus, considering the relevance of school in developing healthy eating habits, this study aimed to characterize and evaluate the food environment of public schools regarding identified healthy eating competing and promoting factors.
METHODS
This cross-sectional, descriptive, and observational study is nested in the research project entitled “Study of the food environment, the acceptability of menu preparations, and the factors associated with adherence to school meals in public schools in the state of Rio de Janeiro” was developed by the Education, Extension and Research Group on Food and School Health (GEPASE). It was conducted in 14 public schools and their surroundings, located in a municipality in the metropolitan region of the state of Rio de Janeiro, whose territorial extension is 133,757 km², with an estimated population of 516,981 inhabitants, and a Human Development Index of 0.83721. The municipality has 95 schools distributed across seven regional centers, of which 46 are for Early Childhood Education (EI) and 49 for Elementary School (EF).
The schools participating in the research were selected by convenience sample under the following criteria: school principals’ agreement to participate in the study and not being located in an area at risk of violence. Six of the 14 schools selected were from EF I, five from EF II, and three from EI (age range 4 years to 5 years and 11 months). Data were collected from the second half of 2021 to the first half of 2022. The audit assessed the food environment through the location’s direct observation22 and was performed on two non-consecutive days through photographic records and a field diary.
The study was approved by the Ethics Committee of the Antônio Pedro University Hospital of the Fluminense Federal University (UFF) and registered with CAAE N° 98417718.5.0000.5243.
Food-related murals, vegetable gardens, school cafeterias, and teachers sitting along during meals13 were considered components that promote a healthy food environment in order to characterize the food environment within schools. The competing factors were snacks brought by children23,24, canteens, informal food outlets12, and packaging and ultra-processed foods circulating in schools and trash cans in the schoolyard.
We performed direct observation at each location to characterize the outlets in the school environment under the components that promote and compete in the healthy food environment, and recording was made in a checklist-type instrument prepared by the researchers based on guidelines in the Resolution FNDE 6/20205 and the Food Guide for the Brazilian Population25. The instrument included the characterization of outlets (market, cafeteria, bakery, kiosk, stall, and trailer) and the availability and types of food and drinks sold, with those considered potential for immediate consumption at school (treats, fruits, juices, sugary drinks, coconut water, cakes, bread, and packaged snacks).
The food environment of the school environment was considered to be any food outlet located within a 500-meter radius from the school gate9. After this stage, the foods and drinks were categorized into food groups and classified per their processing level (fresh or minimally processed, processed, and ultra-processed) under the NOVA26 classification.
All images related to the food environment were recorded using photographs and saved in a text editor spreadsheet. The data were entered into a Microsoft Office Excel 2010 Program database. We used descriptive statistics related to relative (%) and absolute (n) frequency to characterize and explore the food environment in and around schools.

RESULTS
Regarding aspects of the indoor food environment, all five EF II schools had more factors competing with adequate and healthy eating than healthy eating promoting factors. On the other hand, EI and EF I schools had a predominance of promoting factors such as vegetable gardens and healthy eating-related murals (Table 1).
Table 1

Although early childhood education schools do not have ultra-processed food packaging in the bins (Table 1), internal circulation of packaged snacks and guaraná-based sugary drinks was observed by those responsible for the students when picking up their children from school.
In two schools, snacks taken by students were stored in plastic boxes inside refrigerators to be consumed during recess, with students witnessing the removal of these products. In another, we identified a poster on the refrigerator informing the informal sale of a sugary guaraná-based drink. Another aspect that competed with healthy school meals was the distribution of papaya-enriched milk accompanied by a wrapper of Fini® candy around the jug observed in a school.
Regarding the elements that promote a healthy eating environment, we noted some murals on the topic of food strategically available at the cafeterias in two schools. While vegetable gardens were found in four schools, only one was in good conservation, and the remainder required revitalization.
In EI schools, teachers accompanied their students and encouraged food consumption. However, this reality was not observed in elementary schools. In these, some teachers ate lunch in the cafeteria, but there was no dialogue, and meals were not always consumed at the same time as the students.
Fifty-three food outlets were found around the 14 schools, of which 15 (28.3%) were stalls and trailers located next to or in front of the school gates. The others were identified as bars, snack bars, bakeries, açai outlets, and markets. Ultra-processed foods were predominant in these stores (Table 2). Shops selling fresh foods, such as fruits and vegetables, were found around six schools (42.8%). However, ultra-processed foods were sold in the same space and were found in all outlets.
Table 2

DISCUSSION
The results of the present study indicate that, within public schools, factors promoting healthy eating were more available than competing factors, especially at the EI and EF I levels. However, we observed the concomitant availability of healthy and unhealthy foods in the school environment of EF I and II students. At the very least, this paradox confuses students into wanting to try or reject school meals, challenging high adherence and guarantee of food security for students under PNAE’s universality precepts.
The healthier eating environment observed in early childhood education can be explained by Resolution N° 6/2020 of the PNAE5, which, aligned with the dietary guides for the Brazilian population25 and children under two years of age27, determines the prohibition of inclusion of ultra-processed foods and the addition of sugar, honey, and sweeteners in culinary preparations and drinks for schoolchildren under 3. Depending on the part-time or full-time period, for schoolchildren over 3, the weekly/monthly frequency of ultra-processed foods is limited on the menu, and the purchase of these products must correspond to 20% of the total resources transferred by the FNDE5.
The availability of ultra-processed foods stored in school refrigerators and the identification of students consuming these foods during recess shows that, although adequate and healthy food is offered in schools, some students take snacks with them, even in education units with an incentive to adhere to school meals. The storage and informal sale of ultra-processed foods in schools are incompatible with a healthy food environment, as they compete with school meals, contradicting PNAE’s guidelines.
Ultra-processed foods contain high amounts of sodium, sugar, fats, and substances synthesized in the laboratory25. These industrial formulations are hyper-palatable, practical, and convenient for mothers and children, as most of them are already sold and ready to be consumed26,28. Intake of these products contributes to the early development of chronic diseases, such as obesity, diabetes, hypertension, and cancer. They can also cause nutritional deficiencies in childhood, such as hypovitaminosis A and iron deficiency anemia, impairing growth and development, learning capacity, and immunity29.
Although no canteens were found in the schools participating in the study, the sale of sweets and processed drinks was observed in two, in disagreement with the healthy eating environment that school units should promote. The food environment’s influence on decisions about what to eat is already well-founded in the literature30-35. The arrangement and availability of food on supermarket shelves, in vending machines, and the type and availability of food outlets close to homes and workplaces can significantly shape food choices. A meta-analysis with 457 studies to identify associations between the determinants of the built environment and childhood obesity identified consistent associations between more comprehensive access to fast-food foods and their greater consumption36. These studies suggest that a food environment that promotes access to and availability of healthy foods can encourage more nutritious choices. In contrast, the predominant availability of less healthy foods can lead to a less balanced diet. Thus, awareness about the impact of the food environment on food choices is essential for promoting healthier eating habits and preventing diseases related to inadequate nutrition.
In this context, we should consider that the exposure of children and adolescents to unhealthy foods already occurs in different places and formats inherent to their experience, such as television, supermarkets, shopping malls, and street outlets. Therefore, children should be robustly protected against ultra-processed food exposure, commercial appeal, and advertising practices, at least in and around schools.
According to the statute of children and adolescents, healthy eating and adequate nutrition are part of the fundamental rights of all children, and the school is part of the protection network against exposure to unhealthy foods and advertising strategies promoted by the food industry37. Thus, the State advises that schools must promote health, protect children and adolescents’ rights, and provide, promote, and protect adequate and healthy food. Therefore, public policies must mobilize actions to reshape environments, territories, and cities, mainly aiming to encourage healthy practices and guarantee their adoption, changing obesogenic environments38.
In this sense, the school garden can be an essential strategy for reshaping the school environment focusing on food and environmental education, as it stimulates interest in cultivating and consuming healthy foods and sensitizes people on the environment39. A cafeteria in all schools also promotes school meals due to its structural and sensorial characteristics that help people concentrate during meals, allowing the enjoyment of culinary preparations, and making the act of eating a pleasurable moment25.
We should underscore that promoting adequate and healthy eating must be continuous, permanent, intersectoral, and multidisciplinary40. Even if done only through murals, as seen in some schools, it seeks to awaken students’ interest in healthy foods. When strategically planned and used, these devices can encourage students to want to try out the foods offered and increase adherence to school meals41. However, we observed that this methodology has been rarely explored in schools despite the space available for offering these materials.
Although fresh foods were identified in the school environment, ultra-processed foods were found in higher numbers, aligned with similar studies that also found a predominance of ultra-processed foods in the surrounding areas of schools9,15,20. Open-air markets have been identified as encouraging the consumption of healthy foods, as they offer greater variety, better quality, and lower costs. On the other hand, small outlets have products with higher prices and mainly sell ultra-processed products42.
In recent decades, Brazil has been advancing the discussion on the importance of restricting the supply and sale of unhealthy foods in and around schools to promote adequate and healthy eating in childhood. Recently, the Ministry of Health published the National Strategy for the Prevention and Care of Childhood Obesity (PROTEJA), which advocates a healthy food environment as one of the pillars for preventing childhood obesity, considering regular, permanent, and unrestricted access to safe, regional, adequate and healthy foods, aligned with the Food and Nutrition Safety precepts43. However, regulatory measures with legal effect have not advanced, especially regarding the sale of food products in school spaces, showing regulatory and adequate public policy gaps that protect school environments from the supply of ultra-processed products44.
At a national level, interministerial ordinance N° 1010/2006 aims to restrict trade and sale promotion of foods and preparations with high levels of saturated fat, trans fat, free sugar, and salt in the school environment and encourage the consumption of fruits, vegetables, and greens in public and private schools45. In the state of Rio de Janeiro, where the research was conducted, Law Nº 4508 of 2005 specifies products prohibited in schools, such as snacks, chocolate, and treats such as candies, lollipops, sweets, chewing gum, industrialized beverages, soft drinks, and foods containing artificial dyes, preservatives, or antioxidants46.
Although legal provisions guide restricting unhealthy foods in schools, it is still challenging to fully comply with them, even when recognizing that a healthy food environment is essential for promoting Food and Nutrition Safety and ensuring the Human Right to Adequate Food. Therefore, mandatory regulatory measures are required, such as prohibiting the entry of ultra-processed foods into schools, strengthening strategies to support and encourage healthy eating, such as school stakeholders understanding their role in the PNAE so that the issue of food is included in the school curriculum, and ensuring permanent Food and Nutrition Education actions in schools.
The study contributed to observing factors not yet investigated in previous studies, such as teachers sitting along during meals and of ultra-processed foods in schools not restricted to canteens. A limitation is that the number of schools is not representative of the municipality; thus, results cannot be generalized. Schools located in areas with a higher risk of violence and more significant social vulnerability were not included in this research. As a result, we suggest similar studies in this context to investigate whether the school food environment would be more promoting or competing with healthy eating for students.

CONCLUSION
The present study identified more factors that promote healthy eating than competing factors. Although it has not been identified in all schools and was found mainly in early childhood education, the availability of vegetable gardens, murals, and teachers sitting along during meals can potentially promote healthy eating in the school environment. Especially in Elementary Schools I and II, we identified a high availability of ultra-processed foods within schools. The contribution of these foods outweighed fresh and minimally processed foods in the school environment.
The competing factors identified in the study may contribute to low adherence to school meals and, consequently, less healthy eating habits. Other factors besides those investigated can be considered in future studies, considering that healthy eating practices must be encouraged in these spaces to guarantee schoolchildren’s food and nutrition safety. The sale of ultra-processed foods in school areas and the availability of these foods inside schools mischaracterize the food environment as healthy and compete with the food offered within the PNAE.
REFERENCES
1. Swinburn B, Vandevijvere S, Kraak V, Sacks G, Snowdon W, Hawkes C, Barquera S, Friel S, Kelly B, Kumanyika S, L\'Abbé M, Lee A, Lobstein T, Ma J, Macmullan J, Mohan S, Monteiro C, Neal B, Rayner M, Sanders D, Walker C. Monitoring and benchmarking government policies and actions to improve the healthiness of food environments: a proposal Government Healthy Food Environment Policy Index. Obes Rev. 2013; 14 (Suppl 1):24-37.

2. Espinoza PG, Eganã D, Masferrer D, Cerda R. Proposal for a conceptual model for the study of food environments in Chile. Rev. Panam. Salud Pública. 2017; 41e169.

3. Castro IRR, Canella DS. Organizational Food Environments: Advancing Their Conceptual Model. Foods. 2022; 11(7):993.

4. FAO. Organización de las Naciones Unidas para la Alimentación y la Agricultura (FAO). Alimentación y Nutrición Escolar: entornos alimentarios y alimentacion escolar saludables. 2019. [Acessado em 2022 dez 12]. Disponível em: http://www.fao.org/school-food/areas-work/food-enviroment.

5. Brasil. Ministério da Educação. Resolução/CD/FNDE n°6, de 8 de maio de 2020. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de Alimentação Escolar. Brasília, 2020, 8 mai.

6. Andreta V, Siviero J, Mendes KG, Motter FR, Theodoro H. Consumo de alimentos ultraprocessados e fatores associados em uma amostra de base escolar pública no Sul do Brasil. Cienc Saude Colet 2021; 26(4):1477-1488.

7. Silva NAR, Diniz JC. Qualidade nutricional dos lanches levados pelos alunos matriculados nos centros infantis da cidade de Matozinhos-MG. Rev. Bras Cienc da Vida 2018; 6(4):194-212.

8. Cesar JT, Taconeli CA, Osório MM, Schmidt ST. Adesão à alimentação escolar e fatores associados em adolescentes de escolas públicas na região Sul do Brasil. Cien Saude Colet. 2020; 25(3):977-988.

9. Henriques P, Alvarenga CRT, Ferreira DM, Dias PC, Bastos DS, Barbosa RMS, Burlandy L. Ambiente alimentar do entorno de escolas públicas e privadas: Oportunidade ou desafio para alimentação saudável? Cien Saude Colet. 2021; 26(8):3135-3145.

10. Azeredo CM, Rezende LFM, Canella DS, Claro RM, Peres MFT, Luiz OC, França-Júnior I, Kinra S, Hawkesworth S, Levy RB. Food environments in schools and in the immediate vicinity are associated with unhealthy food consumption among Brazilian adolescents. Preven Med 2016; 88:73-79.

11. Lacerda AT, Carmo AS, Sousa TM, Santos LC. Participação de alimentos ultraprocessados na dieta de escolares brasileiros e seus fatores associados. Rev Paul Pediatr 2020; 38: e2019034.

12. Valentim EA, Almeida CCB, Taconeli CA,Osório MM, Schmidt ST. Fatores associados à adesão à alimentação escolar por adolescentes de escolas públicas estaduais de Colombo, Paraná, Brasil. Cad Saude Publica 2017; 33(10): e00061016, 2017.

13. Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Manual operacional para profissionais de saúde e educação: promoção da alimentação saudável nas escolas. Brasília: Ministério da Saúde, 2008.

14. Bryant M, Burton W, O’Kane N, Woodside JV, Grundy C. Developing and implementing food-based dietary guidelines in schools: a qualitative investigation of the perspectives of school stakeholders in England. Int J Behav Nutr Phys Act. 2023; 20(1):29.

15. Peres CMC, Gardone DS, Costa BVL, Duarte CK, Pessoa MC, Mendes LL. Retail food environment around schools and overweight: a systematic review. Nutr Rev 2020; 78(10):841-856.

16. Betts GM, Schwedhelm C, Lipsky LM, Haynie DL, Nansel TR. Impact of the external school food environment on the associations of internal school food environment with high schoolers\' diet and BMI. Public Health Nutr. 2022; 25(11):3086-3095.

17. Swinburn B, Egger G, Raza F. Dissecting Obesogenic Environments: The Development and Application of a Framework for Identifying and Prioritizing Environmental Interventions for Obesity. Prev Med. 1999; 29(6):563–70.

18. Borges CA, Gabe KT, Canella DS, Jaime PC. Caracterização das barreiras e facilitadores para alimentação adequada e saudável no ambiente alimentar do consumidor. Cad Saude Publica. 2021; 37: e00157020.

19. Carmo AS do, Assis MM de, Cunha C de F, Oliveira TRPR de, Mendes LL. The food environment of Brazilian public and private schools. Cad Saude Publica. 2018; 34(12): e00014918.

20. Peres CMC, Costa BVL, Pessoa MC, Honório OS, Carmo AS, Silva TPR, Gardone DS, Meireles AL, Mendes LL. O ambiente alimentar comunitário e a presença de pântanos alimentares no entorno das escolas de uma metrópole brasileira. Cad Saude Publica 2021; 37(5): e00205120.

21. Instituto Brasileiro de Geografia e Estatística (IBGE). Cidades e Estados. Brasil:IBGE, 2023.

22. Glanz K, Sallis JF, Saelens BE, Frank LD. Healthy nutrition environments: concepts and measures. Am J Health Promot 2005; 19:330-3.

23. American Academy of Pediatrics. Council on School Health. Committee on Nutrition.Snacks, Sweetened Beverages, Added Sugars, and Schools.Pediatrics. 2015 Mar; 135(3):575-83.

24. Mello AV, Morimoto JM, Paternez ACAC. Valor nutritivo de lanches consumidos por escolares de uma escola particular. Ciên & Saúde. 2016; 9(2):70-75.

25. Brasil. Ministério da Saúde. Guia Alimentar para a População Brasileira. 2ª ed. Brasília 2014.

26. Monteiro CA, Cannon G, Moubarac JC, Levy RB, Louzarda MLC. The UM Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing. Public Health Nutr.2018; 21:5-17.

27. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para crianças menores de dois anos. Brasília: Ministério da Saúde, 2019.

28. Costa CS, Flores TR, Wendt A, Neves RG, Assunção MCF, Santos IS. Comportamento sedentário e consumo de alimentos ultraprocessados entre adolescentes brasileiros: Pesquisa Nacional de Saúde do Escolar (PeNSE), 2015. Cad Saude Publica 2018; 34(3): e00021017.

29. Lopes WC, Pinho L, Caldeira AP, Lessa AC. Consumo de alimentos ultraprocessados por crianças menores de 24 meses de idade e fatores associados. Rev paul pediatr. 2020; 38: e2018277.

30. Atanasova P, Kusuma D, Pineda E, Frost G, Sassi F, Miraldo M. The impact of the consumer and neighbourhood food environment on dietary intake and obesity-related outcomes: A systematic review of causal impact studies. Soc Sci Med. 2022 Apr; 299:114879.

31. An R, He L, Shen MJ. Impact of neighbourhood food environment on diet and obesity in China: a systematic review. Public Health Nutr. 2020 Feb; 23(3):457-473.

32. Curioni CC, Boclin KLS, Silveira IH, Canella DS, Castro IRR, Bezerra FF, Junger W, Faerstein E. Neighborhood food environment and consumption of fruit and leafy vegetables: Pro-Saude Study, Brazil. Public Health. 2020 May; 182:7-12.

33. Vogel C, Abbott G, Ntani G, Barker M, Cooper C, Moon G, Ball K, Baird J. Examination of how food environment and psychological factors interact in their relationship with dietary behaviours: test of a cross-sectional model. Int J Behav Nutr Phys Act. 2019 Jan 30;16(1):12.

34. Skidmore P, Welch A, van Sluijs E, Jones A, Harvey I, Harrison F, Griffin S, Cassidy A. Impact of neighbourhood food environment on food consumption in children aged 9-10 years in the UK SPEEDY (Sport, Physical Activity and Eating behaviour: Environmental Determinants in Young people) study. Public Health Nutr. 2010 Jul; 13(7):1022-30.

35. Duran AC, de Almeida SL, Latorre Mdo R, Jaime PC. The role of the local retail food environment in fruit, vegetable and sugar-sweetened beverage consumption in Brazil. Public Health Nutr. 2016 Apr;19(6):1093-102.

36. Jia P, Shi Y, Jiang Q, Dai S, Yu B, Yang S, Yang S. Environmental determinants of childhood obesity: a meta-analysis. The Lancet Global Health. 2023; 11, [Special issues] S7.

37. Brasil. Lei nº 8069 de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União 1990; 13 jul.

38. Organização Pan-Americana da Saúde (OPAS). Plano de ação para prevenção da obesidade em crianças e adolescentes. Brasília: Organização Pan-Americana da Saúde; 2015.

39. Doria NG, Coelho DEP, Garcia MT, Watanabe HAW, Bógus CM. A experiência de uma horta escolar agroecológica como estratégia interativa e criativa de promoção da saúde. Demetra; 2017; 12(1):69-90.

40. Brasil. Ministério do Desenvolvimento Social e Combate à Fome. Marco de referência de educação alimentar e nutricional para as políticas públicas. Brasília, DF: MDS. Secretaria Nacional de Segurança Alimentar e Nutricional. 2012.

41. Silva SU, Monego ET, Sousa LM, Almeida, GM. As ações de educação alimentar e nutricional e o nutricionista no âmbito do Programa Nacional de Alimentação Escolar. Ciên Saude Colet.2018; 23(8):2671-2681.

42. Lopes ACS, Menezes MC, Araújo ML. O ambiente alimentar e o acesso a frutas e hortaliças: “Uma metrópole em perspectiva”. Saúde Soc.2017;26(3):764-773.

43. Brasil. Ministério da Saúde. Portaria GM/MS nº 1.862, de 10 de agosto de 2021. Institui a Estratégia Nacional para Prevenção e Atenção à Obesidade Infantil – Proteja. Diário Oficial da União, 2021; 10 ago.

44. Pereira TN, Gomes FS, Carvalho CMP, Martins APB, Duran ACFL, Hassan BK, Cruz JI, Mais LA, Ferraz MA, Mialon M, Johns P, Bandeira LM. Medidas regulatórias de proteção da alimentação adequada e saudável no Brasil: uma análise de 20 anos. Cad Saude Publica. 2021; 37(Supl.1): e00153120.

45. Brasil. Portaria Interministerial nº 1.010, de 08 de maio de 2006. Institui as diretrizes para a Promoção da Alimentação Saudável nas Escolas de educação infantil, fundamental e nível médio das redes públicas e privadas, em âmbito nacional. Diário Oficial da União, 2006; 08 mai.

46. Rio de Janeiro. Lei nº 4508, de 11 de janeiro de 2005. Proíbe a comercialização, aquisição, confecção e distribuição de produtos que colaborem para a Obesidade Infantil, em bares, cantinas e similares instalados em Escolas Públicas e Privadas do Estado do Rio De Janeiro, na forma que menciona. Diário Oficial da União 2005; 11 jan.