Artigos

INTRODUCTION

The Human Right to Adequate Food is the fundamental principle underlying Food and Nutrition Security, defined as the assurance of every individual's right to access quantitatively and qualitatively healthy and sufficient food1. Violation of this right occurs when individuals or groups lack access to food in adequate quantity and quality necessary to meet their nutritional needs, resulting in food insecurity2.
The Brazilian Food Security Scale (EBIA) is a measurement tool that assesses the varying levels of food insecurity. It ranges from mild levels, where there is concern about uncertain access to food, to severe levels characterized by hunger3. The scale was initially developed in 20034 and has since undergone refinement5,6. It is based on the premise that food insecurity is perceived and experienced by families at different levels of severity, providing insight into the psychological and social dimensions of food insecurity beyond mere difficulty in accessing food. Using the EBIA in national surveys contributes to understanding the food insecurity trends in Brazil7.
Food and nutrition insecurity poses a significant challenge that must be addressed to foster the comprehensive development of countries and societies. This issue is integral to the Sustainable Development Goals (SDG) outlined in the United Nations' (UN) Agenda 2030. This agenda has established three key goals: eradicating world hunger, attaining food security, and enhancing global nutrition8.
Establishing healthy eating habits during childhood is essential for mental and physical development. School meals play a crucial role in shaping these habits and contributing to a better quality of life9. Brazil boasts the world's second-largest school feeding program, the National School Feeding Program (in Portuguese – Programa Nacional de Alimentação Escolar - PNAE)10 . The primary objective of PNAE is to promote healthy eating habits among students by providing nutritious meals that meet their nutritional needs. The program also incorporates food and nutrition education initiatives. PNAE covers 80% of the public elementary school network, ensuring that a significant portion of the country's primary education students receive proper meals throughout the school period11.
Despite the relevance of school feeding as a social protection strategy, evidence on the relationship between household food insecurity and school meal consumption in Brazil remains limited and regionally concentrated12. Only two studies have been identified in the southeastern region of the country13,14. Barros et al.14 found that most students from rural areas in Rio de Janeiro who experienced some level of food insecurity consumed school meals. A recent study conducted in the coastal region of Santos, São Paulo, examined this relationship among children and adolescents aged 6 to 17 years in 2018-2019. After adjusting for sociodemographic variables, the study revealed that consumption of school meals remained associated with moderate and severe food insecurity. Students experiencing moderate or severe food insecurity were found to have twice the likelihood of consuming school meals regularly13.
Considering the significance of the PNAE and its core principles of universality and equity, this study aimed to examine the relationship between daily school meal consumption and food insecurity among Brazilian schoolchildren. The hypothesis posited in this study is that there is an association between food insecurity and school meal consumption, suggesting that children from families facing household food insecurity in schools covered by the PNAE are more likely to consume school meals daily. The anticipated outcome of this study is that the findings will contribute to the planning and enhancement of the PNAE as well as other preventive programs, health promotion initiatives, and measures designed to combat food insecurity.

METHODS
Study population

This cross-sectional analysis utilized data from the Household Budget Survey (HBS) conducted by the Brazilian Institute of Geography and Statistics (IBGE). The HBS was conducted between May 2017 and 2018 to assess consumption patterns, expenditures, income levels, and aspects related to income distribution among Brazilian families. The survey aimed to provide insights into the living conditions of households by analyzing their budgetary information15.
The sample consisted of private and permanent households in the national territory, covering all states and urban and rural areas of the country's five regions (North, Northeast, Southeast, South, and Midwest). The survey used a probabilistic sample in two stages, with a complex, stratified and conglomerate sampling plan15.
For the 2017-2018 HBS, a sampling plan called a two-stage conglomerate was adopted, with geographic and statistical stratification of the primary sampling units that correspond to the sectors or aggregates. The primary sampling units (PSU) were selected by sampling with probability proportional to the number of existing households in the sector within each final stratum, composing the master sample. The subsample of PSU for the 2017-2018 HBS was selected by simple random sampling in each stratum15.
Among the 57,920 surveyed households, 17,588 had at least one child, resulting in 19,947 children aged 2 to 9 years. Of these, 16,370 attended school or daycare centers, and 12,951 were enrolled in public schools (79.1% of those attending schools) and included in the analysis.

Data Collection Methodology and Variables Analyzed
Trained teams from the IBGE conducted interviews with the residents of these households over nine days. The data collection involved electronic equipment, such as interviews conducted through electronic devices and the recording of diary entries by household informants15.
The data collected through the questionnaire were utilized to evaluate household-related questions, as well as questions concerning the household's residents and their living conditions. Food consumption information was not assessed as the 24-hour recall method was only applied to individuals aged ten years and above.
In the 2017-2018 edition of the survey, the Brazilian Food Insecurity Scale – EBIA15 was implemented for the first time and served as the exposure variable for the current study. The complete EBIA instrument comprises 14 questions that classify households into four categories based on the number of "yes" or "no" responses, reflecting the household's food security status during the three months before the survey5. Therefore, households are categorized into four levels of food security status (absence, mild, moderate, and severe), according to the cut-off points recommended for households with children. This study used the following classifications: food security, mild food insecurity, and moderate or severe food insecurity.
The independent variable of interest in this study was whether the participants received meals free of charge from public schools. To assess this, the questionnaire included questions for each meal: "Does the child usually have breakfast/snack/lunch/dinner daily at school or daycare?" followed by the question, "Is the morning/snack/lunch/dinner provided by the school or daycare center (free of charge)?" Thus, individuals were considered to receive the school meals if they reported that the child had at least one meal provided by the public school daily.
Based on the existing literature on the socioeconomic determinants of food insecurity in Brazil16, sociodemographic variables were considered covariates in this study. The demographic characteristics of children, including gender (male or female), age groups (2-5 years and 6-9 years), and race/skin color (categorized as white, black/brown, and yellow/indigenous), were evaluated. The study also examined characteristics of the head of the family, such as gender and education level (classified as no education, incomplete elementary school, complete elementary or incomplete secondary education, and completed secondary education or more), as well as race/skin color (categorized as white, black/brown, and yellow/indigenous). Household characteristics were also taken into account, including the number of residents (categorized as up to 3, 4 or 5, and 6 or more), the number of children (classified as 1 or 2, and more than 2), and the number of adolescents in the household (tagged as none, 1 or 2, and 3 or more). Furthermore, information regarding the race/skin color, gender, and education level of the head of the family was also included in the analysis.
To calculate the per capita family income, the total monthly income and the total number of residents per consumption unit were considered, along with the minimum wage in effect on the survey's reference date of January 15, 2018. Income ranges were defined as follows: up to 0.5 times the minimum wage, between 0.5 and 1 times the minimum wage, between 1 and 2 times the minimum wage, and greater than 2 times the minimum wage. Additionally, the location of the household was assessed, distinguishing between rural and urban areas, as well as major regions of Brazil, including the North, Northeast, Southeast, South, and Midwest. The household's specific characteristics were also considered, such as whether the family income was sufficient to cover their expenses.

Data analysis and ethical aspects
In the bivariate phase of the analysis, the proportions and 95% confidence intervals of the variables under investigation were calculated. The chi-square test was applied to assess the association between variables. Poisson regression models were employed to examine the relationship between food insecurity and daily consumption of school meals, controlling for sociodemographic variables that showed a significant association at a significance level of 5%. Non-significant variables were eliminated using a backward elimination approach, retaining only those that remained statistically significant in the adjusted model. The analysis was conducted using Stata software, version 16.0, considering the weighting factors and complex sampling aspects of the 2017-2018 HBS.
Data from the 2017-2018 HBS are freely accessible through the Brazilian Institute of Geography and Statistics (IBGE). Therefore, local Ethics Committee approval from the CEP-CONEP System was not required to use the data.

RESULTS

A total of 12,951 children aged 2 to 9 years were included in the evaluation. Among them, 87.7% consumed the meals offered by the school on a daily basis. The majority (62.0%) was in the age group of 6 to 9 years, and 51.2% were male. Around 45.5% lived in families consisting of 4-5 members, and 51.7% had a per capita family income of less than half the minimum wage. When considering the characteristics of the head of the family, 37.4% had completed secondary school or more, 58.2% were male, 66.3% were black or brown, and 80.4% resided in urban areas (Table 1).
Regarding the prevalence of food insecurity, over half of the children were in households experiencing some degree of food insecurity. Specifically, 35.4% had mild food insecurity, while 19.7% had moderate or severe food insecurity. The prevalence of moderate or severe food insecurity was higher among those living in households with more residents, more children and adolescents, households where the head of the family had lower education, led by women, and where the head of the family identified as black or brown. Moderate or severe food insecurity was also more prevalent among children in households with lower per capita family income, in the North and Northeast regions compared to other regions, and among residents in rural areas (Table 2).
The prevalence of daily consumption of meals provided by public schools or daycare facilities among Brazilian children was 87.7%. This prevalence was significantly higher among children from families experiencing moderate to severe food insecurity, those in the preschool age group, households with a larger number of children, lower household head's educational attainment, lower per capita income, and residents in rural areas (Table 3).
In the Poisson regression analysis, moderate or severe food insecurity remained associated with daily consumption of school meals (PR: 1.04; 95% CI: 1.01; 1.07), while no significant association was found with mild food insecurity, after adjustment for sociodemographic variables (Table 4).

DISCUSSION

The results of our study reveal that more than half of Brazilian children between 2 and 9 years of age, who attended public schools, lived in households with some level of food insecurity in 2017/2018. This result ratifies the situation of social vulnerability of these families. Food insecurity was positively associated with daily consumption of school meals, revealing a 4% higher prevalence among children hailing from families experiencing moderate or severe food insecurity. Although statistically significant, this small effect size should be interpreted with caution, particularly given the high prevalence of daily school meal consumption observed. In this sense, while the magnitude of the association is limited, the results are consistent with the role of the PNAE as a universal policy with capacity to reach socially vulnerable groups.
The high prevalence of children in families experiencing food insecurity found in this study is in line with what has been observed since 2015, with the worsening of the economic crisis in Brazil. Between 2014 and 2018, the proportion of people living below the poverty line - that is, living on less than $5.50 a day - increased from 22.8% to 25.3% (52.5 million), and the proportion of people living below the extreme poverty line - those living on up to $1.90 a day - increased from 4.5% to 6.5%, representing 13.5 million people (IBGE, 2019). In addition to this scenario, there was a weakening of food and nutritional security policies, such as changes in assistance programs and budget cuts in the Family Farming Food Acquisition Program13.
Fernandes18 reinforces that the Human Right to Adequate Food does not happen dissociated from structuring actions. In the difficulty in obtaining income, the State must assume its place and find ways to realize this right. The results of the present study suggest that the PNAE plays an essential role in providing access to at least one healthy daily meal among children in schools and daycare, showing the importance of actions to increase its coverage and the quality of the food offered. In a recent systematic review of the literature, Silva et al.19 evaluated 12 studies and found that the requirements of the PNAE for nutritional adequacy were not met for most of the evaluated nutrients. The authors hypothesized that the observed inadequacies are due to the increased purchase and supply of ultra-processed foods. The evidence shows that these foods are negatively associated with the consumption of micronutrients such as iron, zinc, and fiber20.
Although the PNAE guidelines restrict the inclusion of ultra-processed foods and prioritize meals based on fresh or minimally processed ingredients, the absence of adequate infrastructure for food preparation and meal service may limit compliance with these standards. In such contexts, school feeding may rely more heavily on ready-to-eat or ultra-processed items as substitutes for freshly prepared meals, diverging from dietary guidelines and potentially compromising nutritional quality21,22.
In this study, it was found that 87.7% of the children in the sample consumed the meals offered by the school or daycare daily. This percentage is, similar to what was estimated in a previous national survey conducted between 2008 and 2009, which reported a consumption rate of 90.6% among children from public schools23. However, daily consumption was more frequent among preschool children (2-5 years old) when compared to children aged 6 to 9 years, highlighting the need to better understand lower adherence among older beneficiaries to strengthen program design.
The association between food insecurity and daily consumption of school meals observed in this study aligns with findings from previous studies conducted in the southern region of Brazil, studies also reported a positive relationship between school meal consumption and food insecurity among children13,14. Moreover, the study by Horta et al. (2019) in Minas Gerais revealed a higher proportion of children with regular consumption of school meals in areas characterized by high/very high social vulnerability risk (76.2%) compared to areas with low/medium risk (68.7%).
Although this study did not evaluate nutritional or developmental outcomes, previous studies have underscored the potential of school feeding programs to improve nutrition and provide food security, especially for children from families in vulnerable situations12. By ensuring regular access to meals aligned with nutritional guidelines, school feeding may help reduce dietary inadequacies and nutritional vulnerability during childhood, thereby supporting healthy child development.
Considering the socioeconomic profile of the families related to food insecurity, the results of the present study were similar to those verified by previous studies in Brazil12,24. According to IBGE15, in Brazil, the average monthly household expenditure in Brazil in 2017-2018 was BRL 4,649.03, being 7.2% higher in urban areas (BRL 4,985.39) and 45.3 % lower in rural areas (BRL 2,543.15), the average income varies between the regions of the country, with the highest values occurring in the Midwest (BRL 5,762.12) and Southeast (BRL 5,415.49). North (BRL 3,178.63) and Northeast (BRL 3,166.07) were below average.
These regional differences should be considered for health promotion actions and coping with food insecurity throughout the national territory since the present study showed the highest prevalence of families in a situation of food insecurity in the North and Northeast regions, contrasting with the results from a recent study that showed the lowest supply of school meals in the North and Northeast regions, as well as in schools in rural areas25, according to data from the National School Health Survey carried out in 2015.
The findings of this study are based on data collected before the Covid-19 pandemic in Brazil. It is essential to consider that the pandemic has further worsened the existing economic crisis in the country. Before the pandemic, there was already a concerning trend in terms of food insecurity in Brazil. Research conducted by Salles-Costa et al.7 indicates that since 2013, food insecurity has increased by 269%, and the proportion of households experiencing food security has decreased by 46.4%.
Moreover, the Food Budget Survey of 2017-2018 revealed that food expenses ranked the second highest expenditure for families. These highlight the urgent need to address the issue of food insecurity and its impact on households in Brazil, particularly in light of the economic challenges exacerbated by the Covid-19 pandemic15.
Among the limitations of the present study, it should be considered that the consumption of school meals was not differentiated in terms of number of meals or weekly frequency of consumption. According to guidelines of PNAE, for students enrolled in primary education, recommendations should be 20% of nutritional needs for one meal and 30% for two or more meals in full-time schools, and nutritional needs should also meet 70% of food intake among enrolled students, full-time, spread over at least three meals26. Such information would allow evaluation according to consumption frequency or differentiated by school shift. Furthermore, it should be noted that the implementation of the PNAE is heterogeneous across the national territory, with important divergences in program execution, indicating that not all schools ensure the regular provision of meals prepared in adequate kitchens and served in appropriate dining facilities21. These territorial disparities may compromise both the composition and the nutritional adequacy of the meals offered, as well as compliance with the standards established by FNDE Resolution No. 4/2026. In this context, reported consumption of school meals does not necessarily reflect uniform access to nutritionally adequate meals, reinforcing the relevance of discussions on the sufficiency of federal transfers and the need for strengthened co-financing to ensure food and nutrition security among beneficiaries.
Another limitation of the study was the absence of the mother's education due to how the information on the household residents was informed, having only their relationship with the reference resident. Therefore, it is suggested to develop new studies on the subject, incorporating this information.
However, to the best of our knowledge, the present study is the first to evaluate the association between the consumption of school meals and the food insecurity situation of families of children aged 2 to 9 years old with a nationally representative sample. The results reinforce the importance of school meal programs in addressing food insecurity among children. They highlight the potential of such programs to target and support children who are most at risk of experiencing inadequate access to nutritious food. It underscores the need for continued efforts to strengthen and expand school meal programs, ensuring their reach to the most vulnerable populations and effectively combating food insecurity.
Furthermore, it is known that the fight against food insecurity must be intersectoral, so the principle of the right to food must be based on promoters of healthy eating, family farming, food and nutrition surveillance, education, and agroecology. Therefore, implementing supportive policies that target the underlying causes of household food insecurity.


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