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Positive influence of school meals on food consumption in Brazil
Accepted Manuscript Title: Do school meals influence the food consumption? the view from brazi Author: Nathália Tarossi Locatelli, Daniela Silva Canella, Daniel Henrique Bandoni PII: DOI: Reference:
S0899-9007(18)30089-3 https://doi.org/10.1016/j.nut.2018.02.011 NUT 10152
To appear in:
Nutrition
Received date: Revised date: Accepted date:
18-5-2017 1-2-2018 7-2-2018
Please cite this article as: Nathália Tarossi Locatelli, Daniela Silva Canella, Daniel Henrique Bandoni, Do school meals influence the food consumption? the view from brazi, Nutrition (2018), https://doi.org/10.1016/j.nut.2018.02.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Do school meals influence the food consumption? The view from Brazi
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Running title: Impact of school meals on food consumption
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Nathália Tarossi Locatellia
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Daniela Silva Canellab
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Daniel Henrique Bandonia
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a
Instituto de Saúde e Sociedade, Universidade Federal de São Paulo. Rua Silva Jardim, 136, Santos, SP 11015-020, Brasil. Nathalia E-mail: [email protected]. Daniel E-mail: [email protected] b
Instituto de Nutrição da Universidade do Estado do Rio de Janeiro, Rua São Francisco Xavier, 524, Rio de Janeiro, RJ 20550-013, Brasil. Daniela E-mail: [email protected]
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Corresponding author:
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Daniel Henrique Bandoni
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Professor, Instituto de Saúde e Sociedade, Universidade Federal de São Paulo. Rua Silva Jardim, 136, Santos, SP, Brasil, 11015-020. Phone +55 (13) 32290100. E-mail: [email protected]
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Sources of funding: This study was supported by the Sao Paulo Research Foundation (Fundação de Amparo a Pesquisa do Estado de São Paulo, FAPESP), n. 15/14881-4, which was awarded to Daniel Henrique Bandoni.
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Conflict of interest: The authors state that there are no conflicts of interest.
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Authors’ contributions: All authors contributed to study conception, statistical analysis and interpretation, manuscript conception, writing, and final revision.
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Ethics Statement: The research project was approved by the National Research Ethics Committee (Registration No. 16,805).
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Highlights
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Brazil implements a national policy requiring public schools to offer meals to students.
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Food consumption between students who eat or not eat meals at school was compared.
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School meal consumption affects positively the overall quality of diet, increases the consumption of healthy diet indicators, and decreases the consumption of unhealthy ones.
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The effect of school feeding programs that offer free meals in school can positively impact on food habits.
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ABSTRACT
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Objective: To analyze the contribution of school meals to the healthy food consumption of public school students in Brazil.
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Methods: The data from the National Adolescent School-Based Health Survey (PeNSE), containing 86,660 ninth-grade students, were used. The students were asked about their consumption of school meals and of food in general over the past seven days and on the day before the interview. A multinomial regression was performed to assess the relationship between the students’ food consumption over the past seven days and regular consumption of school meals (>3 days/week), which were adjusted for sociodemographic factors. Poisson regression models were used for the relationship between food consumed on the day before the interview and regular consumption of school meals.
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Results: Nearly one in five students (22.8%) stated that they consume school meals regularly. The adjusted analyses revealed that the consumption of school meals was associated positively with moderate (3-4 days/week) and regular (>5 days/week) consumption of beans, raw or cooked vegetables, cooked vegetables, and fruits, and with moderate consumption of raw vegetables. In addition, school meal consumption was associated negatively with moderate or regular consumption of fried salty snacks and processed meat, and with regular consumption of packaged salty snacks, crackers, sweet biscuits, and sweets. Based on food consumption on the day preceding the interview, the consumption of school meals significantly affect the consumption of raw and cooked vegetables, and fruits.
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Conclusion: School meal consumption affects positively the consumption of healthy foods and keeps the students from consuming unhealthy foods.
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KEYWORDS: School meals; Food consumption; Adolescent; Food policy; Healthy Diet, Nutritional Requirement.
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INTRODUCTION
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Adolescence is recognized as an important stage for the development of eating habits, and thus it is a period of nutritional risk [1]. This period of life is considered critical to building a healthy eating pattern, because poor eating habits during childhood and adolescence increase the risk of adult obesity [2,3]. However, a significant growth in the prevalence of obesity is observed globally, including among children and adolescents [4,5].
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In Brazil, compared with adults and the elderly, the dietary intake of adolescents is marked by a lower consumption of beans, vegetables, and salads, and a higher consumption of soft drinks, juices, milk drinks, ice cream, sandwiches, sausages, savory snacks, and packaged food and cookies [6]. According to a national survey in 2012, ninth-grade students reported regular consumption of sweets (41.3%), soft drinks (33.2%), and sweet biscuits (32.5%), aside from fruits (30.2%) [7]. Poor eating habits, such as skipping breakfast and dinner, have also been described [8].
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Given the importance and influence of the environment on food practices, the school environment has been considered strategic in promoting health and healthy eating habits [9,10,11]. Previous studies have shown a consistent positive effect of school feeding programs on energy intake and micronutrient status of school-aged children [12].
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In Brazil, free meals are offered through the Brazilian School Food Program [Programa Nacional de Alimentação Escolar (PNAE)], which started in the 1950s and is one of the largest and successful school feeding programs in the world [13]. To promote healthy eating habits among students, thereby enhancing their development and school performance, this program offers meals during school hours for all students enrolled in public schools throughout the country [14]. Most schools offer one daily meal per student during the period of class. The PNAE guidelines follow the principles that value meals prepared in schools with natural or minimally processed foods and avoid products, such as sugary drinks, sausages, and processed meat [15]. In 2015, the program served meals for 42.6 million students.
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Although the importance of food school environment most of studies have been conducted in the United States and European countries. The present work aims to address this research gap, in the context of the importance of the food school environment and the comprehensive reach of the Brazilian school feeding program. This study compares food consumption between Brazilian students who regularly consume and do not regularly consume meals offered in schools. Thus, considering the impact of healthy eating during childhood and adolescence on adult eating habits, this study aims to analyze the influence of school meals served by the PNAE on food consumption among students enrolled in Brazilian public schools.
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METHODS
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Database and samples
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This study used data from the National Adolescent School-based Health Survey (PeNSE) in 2012. The survey was conducted through a partnership between the Brazilian Institute of Geography and Statistics (IBGE) and the Ministry of Health, with support from the Ministry of Education. This study was approved by the National Research Ethics Committee (Registration No. 16,805).
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The PeNSE investigated risk and protective factors concerning the health of adolescents, in a sample of ninth-grade students attending daytime classes at public and private elementary schools, located in urban and rural areas in Brazil. The 2010 School Census was used for sample selection in this study; schools with less than 15 enrollees in academic year 2012were excluded [16].
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The sampling process was different among students living in capital and non-capital cities. Regarding the former, the 26 capitals of States and the Federal District were defined as a geographic stratum (27 strata). A sample of schools was selected in each 27 strata, and in each school, a sample of classes was selected. Regarding the latter, the geographical regions in the North, Northeast, Southeast, South, and Midwest were considered five geographic strata. Schools from each five strata were grouped according to homogeneity and proximity criteria, with groups of about 300 to 600 classes. A sample of these groups was selected from each major region. In both capital and noncapital cities, all students in the selected classes who were present on the day of data collection were asked to answer the survey questionnaire. All participants gave an informed consent [16].
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The PeNSE included 2,842 schools and 4,091 classes. Of the 132,123 students attending these classes, 110,873 were present on the day of data collection, whereas 1,651 opted not to participate and 118 were excluded for not disclosing their age or sex. Therefore, 109,104 students (83%) participated in the survey [16], but the analyses of this study considered only the 86,600 students (82.8%) who were attending public schools.
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Data collection and study variables
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The data collection was conducted by IBGE from April to September 2012. The analyses of this study used the modules of the questionnaire related to food consumption and sociodemographic characteristics. The survey was self-administered using a smartphone [16]. The students were asked about their food consumption over the last seven days prior to the interview and on the day before the interview. These dietary indicators showed satisfactory validity in research conducted in Brazil [17].
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Regarding food consumption over the past seven days, the students were asked about healthy (beans, raw or cooked vegetables, raw vegetables, cooked vegetables, fruits, and milk) and unhealthy (fried salty snacks, processed meat, crackers, sweet biscuits, packaged salty snacks, sweets, and soft drinks) diet indicators. For each of these foods, the following question was
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asked, “WITHIN THE LAST 7 DAYS, on how many days did you eat or drink (name of food or drink)?” The students were divided into three categories based on their responses:
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1. Did not consume: This category included students who indicated that they did not consume (name of food or drink) within the past seven days, or that they consumed the item in one to two days of the past seven days.
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2. Consumed moderately: This category included students who reported that they had consumed (name of food or drink) in three to four days of the past seven days.
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3. Consumed regularly: This category included students who reported that they consumed (name of food or drink) in five to seven days of the past seven days.
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Regarding food consumed on the day before the interview, the dietary intake of raw vegetables, cooked vegetables, and fruits was analyzed by asking the following questions: “Yesterday, in which meals did you eat raw vegetables? Examples: lettuce, tomato, carrot, cucumber, onion, etc.” “Yesterday, in which meals did you eat cooked vegetables, not counting potatoes and cassava (manioc)?” and “Yesterday, how many times did you eat fruit?” The students were divided into two categories based on their responses:
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1. Did not consume: This category included students who indicated that they did not consume the indicated item on the day before the interview.
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2. Consumed: This category included students who consumed the food at least once.
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The exposure variable of this study was related to the consumption of school meals. Such variable was obtained by asking the following question: “Do you usually eat the meals offered by the school?” For the analyses, responses were grouped into two categories, as indicated in the PeNSE:
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1. Do not consume school meals regularly: This category included the responses “My school does not offer meals,” “No, I do not usually eat the meals offered by the school,” “Yes, 1 to 2 days a week,” and “Yes, but seldom.”
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2. Consumes school meals regularly: This category included the responses “Yes, 3 to 4 days a week” and “Yes, every day.”
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The following sociodemographic factors were considered: sex, race/color (white, black, mixed, Asian, indigenous), age (grouped into ≤ 13 years, 14 and 15 years, and ≥ 16 years), geographic region (North, Northeast, Southeast, South, Midwest), location of school (capital or non-capital city), living with parents (living with both parents, living with the mother only, living with the father only, or not living with parents), employment status, and maternal education (none, incomplete elementary school, complete elementary school/incomplete high school, complete high school, or some higher education, whether complete or incomplete).
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As 17.6% (n = 15,265) of the students did not know how to answer the question on maternal education, missing values were obtained through multiple imputations, given that these values were conditioned to other variables [18]. For the imputation, all the variables used in the analysis and those related to
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income were employed; in addition to outcome (food intake) and exposure (school meals), the authors used sex, race/color, region, location of school, father’s education, living with parents, employment status, household goods (car, landline, mobile phone, and number of bathrooms in the house), services (maid and internet access at home), and the primary sampling units (PSU), because of the complexity of the sample. The multiple imputation by chained equations (MICE) was sequential regression multivariate imputation where all missing values of maternal education are regressed on all other used variables, and the missing values are replaced by simulated draws from the corresponding posterior predictive distribution [18].
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Data analysis
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For data analysis, the students were characterized according to sociodemographic factors. To evaluate the differences between the students who consumed and did not consume school meals, Pearson’s chi-square tests were performed, and values of p < 0.05 were considered significant.
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Association analyses between food consumption within the past seven days prior to the interview (outcome) and regular consumption of school meals (exposure), which were adjusted for sociodemographic characteristics, were performed by multinomial regression with 95% confidence intervals. Analyses on food consumed on the day before the interview (outcome) and consumption of school meals (exposure) were performed by Poisson regression models that generated prevalence ratios, with 95% confidence intervals. The final models included the variables that were associated significantly with food consumption (p < 0.05) or that altered the prevalence ratios by at least 10%.
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For all analyses, the program Stata/SE version 12.1 was used, considering the complex sample design of the survey.
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RESULTS
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The data from 86,660 ninth-grade students enrolled in public schools were analyzed. Nearly one in five students (22.8%) stated that they consume school meals regularly. Most of them were enrolled in schools located in the Midwest (30.0%) region and few in the Southeast (20.4%) region. Those who reported to consume school meals regularly comprised of 52.5% female and 63.7% male, aged between 14 and 15 years old. Of these students, 14.0% were employed; 56.9% lived with their mother and father; and 79.8% lived in noncapital cities (p < 0.01 in the chi-square test). With respect to maternal education, 34.7% of their mothers did not complete elementary school; 23.7% finished high school; and 10.8% did not study (p < 0.01 in the chi-square test).
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A statistically significant difference was found between students who had regular and did not have regular consumption of school meals. A higher consumption of beans, raw or cooked vegetables, raw vegetables, cooked vegetables, and fruits was observed among students who regularly consume and do not regularly consume school meals. Accordingly, a lower consumption of fried salty snacks, processed meat, crackers, sweet biscuits, and sweets was
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observed among those who regularly consume and do not regularly consume school meals regularly (Table 1).
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As shown in Table 2, in there was a statistically significant relationship between the regular consumption of school meals and moderate or regular eating of beans, cooked or raw vegetables, cooked vegetables, and fruits. A higher consumption of these types of food was observed among school children who consumed school meals. Correspondingly, there was a statistically significant relationship between the regular consumption of school meals and the consumption of fried salty snacks, and processed meat,. A lower consumption of these types of food was observed among those who consumed school meals.
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Statistically significant differences were observed in the consumption of raw vegetables, cooked vegetables, and fruit by students on the day before the interview, based on the regularity of consumption of school meals (Table 3). Both in the crude and adjusted models, the regular consumption of school meals was significantly associated with a higher consumption of raw vegetables, cooked vegetables, and fruits on the day before the interview (Table 4).
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DISCUSSION
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The regular consumption of school meals was associated positively with the consumption of healthy foods, and consistently, school meal consumption was associated with a lower consumption of unhealthy foods; these findings suggest that school meals can promote healthy dietary practices among students. Thus, healthy food [19] must be included in the meals served in schools, which must use basic foodstuffs and respect the eating habits, food culture, dietary recommendations, sustainability, and agricultural diversification of the region [20]. The PNAE rules has already imposed a ban on the purchase of sweetened drinks and a restriction on canned foods, processed meat, sweets, compound foods (two or more foods packaged separately for joint consumption), half-finished or ready-made preparations for consumption, and concentrated foods [20]. However, the menus offered in public schools do not always follow the PNAE guidelines. Previous studies have pointed out that certain schools offer limited fruits, vegetables, and variety of foods; they also frequently prepare meals that contain food rich in sugars, fat, and sodium [21,22].
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The importance of food offered in schools has also been observed in other countries, such as the US and France. Among North-American lowincome adolescents, consumption of school meals was associated with a higher intake of fruits and vegetables [23]. In the same way, the results of the third School Nutrition Dietary Assessment Study in the US verified that the consumption of school meals is associated positively with the consumption of fresh fruits, whole grains, and a greater variety of vegetables [24]. In France, in accordance with a national policy, school cafeterias serve students meals that prioritize the supply of healthy foods. As a result, children and adolescents (from 3 to 17 years old) who regularly eat at school cafeterias consume more fruits, fish, and sweet biscuits, or cakes and fewer sandwiches and soft drinks [25]. Although the age range of the students studied is wider than in this study,
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both studies observed a similar finding: school meal favors the consumption of healthy foods, but it does not prevent students from consuming unhealthy foods once these foods are also available at schools.
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This study found that among students who regularly consume school meals, there is a regular consumption of vegetables, beans, and fruits. The ninth-grade students enrolled in public schools in Rio de Janeiro City exhibited a regular consumption (at least five times a week) of beans (83.1%), milk (55%), and fruit (45.8%), however they also consume sweets (46.7%) and soft drinks (36.7%). Meanwhile, a small percentage of these students had a regular consumption of raw (19.9%) or cooked vegetables (16.5%) [26].
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The consumption of fruits and vegetables on the day before the interview was higher among students who reported consuming school meals, which may be attributed to the meal served at the school. In a city in the State of Pernambuco, the daily consumption of fruits and vegetables among adolescents from public schools was investigated; it was found that 10.0% of them did not eat fruits and 30.7% did not eat vegetables, whereas 32.9% ate fruits, 29.9% ate vegetables, and only 6.5% ate both. The consumption of fruit and vegetables was 2.4 times higher among adolescents who ate rice and beans daily [27], which is an example of a food provided in Brazilian school meals.
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In European countries, adolescents were found to consume more potatoes and fewer sweets in school at lunchtime compared with other countries. Although the standards of the school meals may differ among European countries studied, these results, although positive, are limited, suggesting that schools do not seem to use their full potential to provide a healthy meal. In addition, adolescents must be encouraged to stay at school to have lunch and not to look for other places that can offer unhealthy meals [28].
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Considering the PNAE guidelines, food and nutrition education in schools can be a powerful tool for promoting adequate and healthy diet and for improving the consumption of school meals. More importantly, the increased consumption of food offered in schools, together with healthy menus, can impact the promotion of healthy eating habits.
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Offering food at school can improve children’s educational progress, and the role of schools in teaching healthy diet can have an important impact on the food system and health of the population [29,30,31]. The results as this study pointed the positive impact of a school food program, based on a guideline that values natural and minimally processed foods. Because dietary intake is constrained by energy consumption, the offer and consumption of more healthy food in school may reduce the daily consumption of other unhealthy foods [32].
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This study has certain limitations that will be discussed below. The PeNSE was carried out among students who were in their last year of elementary school (ninth grade), which may interfere with the adherence to school meals, as older students appear to have worse acceptance of food offered in schools [33]. The effect observed in the present study could be greater if the younger students were included. This study also did not consider the menu offered in schools, so it is not possible to identify whether the offered meals are responsible for the supply of the healthy foods evaluated. However, based on the PNAE guidelines, it is reasonable to assume that the program has
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an important role in promoting healthy eating. Finally, because of the reference period for data collection of food consumption, it is not possible to say that consuming school meals results in habitual consumption of healthy foods.
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In conclusion, this is the first study that showed the effect of a universal school feeding program in the diet indicators associated with the increase and decrease risk of obesity and chronic diseases. The regular consumption of school meals influences the eating habits of ninth-grade students enrolled in public schools in Brazil, and promotes a healthy diet. The students’ consumption of school meals was associated positively with that of healthy foods. School meal consumption also acts as protection, as it was associated with a lower consumption of unhealthy foods. Strengthening school feeding programs with free meals, and encouraging students to consume these meals can be important tools in promoting healthy eating habits.
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ACKNOWLEDGMENTS
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This research was supported by the Sao Paulo Research Foundation (Fundação de Amparo a Pesquisa do Estado de São Paulo, FAPESP), n. 15/14881-4. The support was awarded to Daniel Henrique Bandoni.
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17. Tavares LF, Brito FSB, Passos MDC, Cardoso LO, Levy RB, Castro IRR (2014). Validade relativa de indicadores de práticas alimentares da Pesquisa Nacional de Saúde do Escolar entre adolescentes do Rio de Janeiro, Brasil. Cad. Saúde Pública. 30, 1029–1041.
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Table 1. Food consumption of students in the last seven days, according to the regular consume school meals. Brazil, 2012. Consume school meals regularly Foods
Yes
No
N
(%)
n
(%)
Did not consume
3,397
16.73
14,547
22.03
Consumed moderately
2,926
14.41
10,825
16.39
Consumed regularly
13,981
68.86
40,675
61.58
Did not consume
8,635
42.56
31,029
47.00
Consumed moderately
4,145
20.43
12,703
19.24
Consumed regularly
7,507
37.00
22,283
33.75
Did not consume
10,994
54.23
38,526
58.38
Consumed moderately
3,480
17.16
10,519
15.94
Consumed regularly
5,800
28.61
16,952
25.69
Did not consume
13,897
68.55
47,803
72.43
Consumed moderately
3,232
15.94
9,387
14.22
Consumed regularly
3,144
15.51
8,809
13.35
Did not consume
9,764
48.18
33,233
50.37
Consumed moderately
4,371
21.57
13,783
20.89
Consumed regularly
6,131
30.25
18,964
28.74
Did not consume
7,533
37.16
24,001
36.36
Consumed moderately
2,896
14.29
8,879
13.45
Consumed regularly
9,843
48.55
33,125
50.19
Did not consume
14,183
69.94
42,792
64.81
Consumed moderately
3,578
17.64
12,743
19.30
Consumed regularly
2,517
12.41
10,493
15.89
Beans**
Raw or cooked vegetables**
Raw vegetables*
Cooked vegetables**
Fruit**
Milk
Fried salty snacks**
Page 13 of 18
Processed meat** Did not consume
14,492
71.44
44,844
67.94
Consumed moderately
3,318
16.36
12,147
18.40
Consumed regularly
2,475
12.20
9,017
13.66
Did not consume
8,855
43.68
27,620
41.83
Consumed moderately
4,737
23.36
15,183
23.00
Consumed regularly
6,682
32.96
23,221
35.17
Did not consume
10,083
49.79
31,069
47.13
Consumed moderately
4,318
21.32
13,836
20.99
Consumed regularly
5,852
28.89
21,010
31.87
Did not consume
15,424
76.10
48,897
74.10
Consumed moderately
2,618
12.92
8,920
13.52
Consumed regularly
2,226
10.98
8,169
12.38
Did not consume
8,727
43.04
25,989
39.38
Consumed moderately
3,797
18.73
12,398
18.79
Consumed regularly
7,752
38.23
27,602
41.83
Did not consume
7,533
37.16
24,001
36.36
Consumed moderately
2,896
14.29
8,879
13.45
Consumed regularly
9,843
48.55
33,125
50.19
Crackers**
Sweet biscuits**
Packaged salty snacks
Sweets**
Soft drinks
478
*p<0.05 in the chi-square test
479
**p<0.01 in the chi-square test
480 481 482
Page 14 of 18
483 484 485
Table 2. Multinomial regression results for the association between food consumption in the seven days prior to the interview and the regular consume school meals. Brazil, 2012. Relative Foods
risk,
Relative 95% CI
risk,
crude
adjusted*
1
1
95% CI
Beans Did not consume Consumed moderately
1.16†
1.05 1.29
1.15†
1.04 1.25
Consumed regularly
1.36†
1.16 1.60
1.28†
1.10 1.47
Raw or cooked vegetables Did not consume
1
1
Consumed moderately
1.17†
1.08 1.26
1.16†
1.08 1.26
Consumed regularly
1.17†
1.06 1.29
1.16†
1.05 1.27
Raw vegetables Did not consume
1
1
Consumed moderately
1.09†
1.03 1.15
1.10†
1.04 1.16
Consumed regularly
1.08
0.99 1.17
1.06
0.98 1.15
Cooked vegetables Did not consume
1
1
Consumed moderately
1.26†
1.17 1.35
1.26†
1.17 1.36
Consumed regularly
1.27†
1.20 1.34
1.30†
1.23 1.37
Fruit Did not consume
1
1
Consumed moderately
1.09†
1.04 1.15
1.12†
1.07 1.17
Consumed regularly
1.08†
1.02 1.14
1.07†
1.03 1.12
Milk Did not consume
1
11
Consumed moderately
1.03
0.94 1.13
1.03
0.94 1.12
Consumed regularly
0.94
0.85 1.05
0.93
0.83 1.04
Fried salty snacks Did not consume
1
1
Consumed moderately
0.89†
0.81 0.98
0.89†
0.81 0.97
Consumed regularly
0.71†
0.64 0.79
0.74†
0.63 0.86
Page 15 of 18
Processed meat Did not consume
1
1
Consumed moderately
0.83†
0.78 0.88
0.83†
0.77 0.88
Consumed regularly
0.88†
0.80 0.97
0.90†
0.83 0.97
Crackers Did not consume
1
1
Consumed moderately
0.80†
0.75 0.86
0.99
0.93 1.05
Consumed regularly
0.90†
0.85 0.97
1.08†
1.01 1.16
Sweet biscuits Did not consume
1
1
Consumed moderately
0.41†
0.36 0.45
0.91
0.80 1.03
Consumed regularly
0.82†
0.73 0.92
0.84†
0.74 0.94
Packaged salty snacks Did not consume
1
1
Consumed moderately
0.92
0.81 1.03
0.92
0.81 1.05
Consumed regularly
0.89†
0.82 0.97
0.91†
0.84 0.98
Sweets Did not consume
1
1
Consumed moderately
0.91†
0.88 0.94
0.95
0.88 1.03
Consumed regularly
0.80†
0.73 0.88
0.84†
0.76 0.93
Soft drinks Did not consume
1
1
Consumed moderately
1.03
0.94 1.13
1.03
0.94 1.12
Consumed regularly
0.94
0.85 1.05
0.93
0.83 1.04
486 487
*Adjusted for the variables: region, capital vs. non-capital cities, sex, race/color, maternal education, age, living with parents, working
488
†
Significant variables (p <0.05) in the Poisson regression model
489
Page 16 of 18
490 491
Table 3. Food consumption of students on the day before the interview, according to the regular consumption of school meals. Brazil, 2012. Consume school meals regularly Consumption Foods
Yes
No
N
(%)
n
(%)
No
9,439
46.51
33,816
51.22
Yes
10,856
53.49
32,199
48.78
No
11,633
57.38
40,281
61.06
Yes
8,641
42.62
25,690
38.94
No
7,694
37.92
26,658
40.38
Yes
12,594
62.08
39,362
59.62
Raw vegetables*
Cooked vegetables*
Fruit*
492
*p<0.01 in the chi-square test
493 494 495
Page 17 of 18
496 497 498
Table 4. Poisson regression results for the association between food consumption on the day before the interview and the consumption of school meals. Brazil, 2012. Consumption Foods
Prevalence ratio
95% CI
Prevalence ratio
crude
adjusted*
No
1
1
Yes
1.06†
95% CI
Raw salad* 1.02 1.10
1.06†
1.01 1.10
Cooked vegetables No
1
Yes
1.11††
1 1.08 1.13
1.11††
1.08 1.13
Fresh fruit No
1
Yes
1.04†
1 1.02 1.06
1.03†
1.01 1.05
499 500
*Adjusted for the variables: region, capital vs. non-capital cities, sex, race/color, maternal education, age, living with parents, working
501
†
502
††
Significant variables (p <0.05) in the Poisson regression model Significant variables (p <0.001) in the Poisson regression model
503 504 505
Page 18 of 18
S0899-9007(18)30089-3 https://doi.org/10.1016/j.nut.2018.02.011 NUT 10152
To appear in:
Nutrition
Received date: Revised date: Accepted date:
18-5-2017 1-2-2018 7-2-2018
Please cite this article as: Nathália Tarossi Locatelli, Daniela Silva Canella, Daniel Henrique Bandoni, Do school meals influence the food consumption? the view from brazi, Nutrition (2018), https://doi.org/10.1016/j.nut.2018.02.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Do school meals influence the food consumption? The view from Brazi
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Running title: Impact of school meals on food consumption
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Nathália Tarossi Locatellia
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Daniela Silva Canellab
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Daniel Henrique Bandonia
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a
Instituto de Saúde e Sociedade, Universidade Federal de São Paulo. Rua Silva Jardim, 136, Santos, SP 11015-020, Brasil. Nathalia E-mail: [email protected]. Daniel E-mail: [email protected] b
Instituto de Nutrição da Universidade do Estado do Rio de Janeiro, Rua São Francisco Xavier, 524, Rio de Janeiro, RJ 20550-013, Brasil. Daniela E-mail: [email protected]
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Corresponding author:
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Daniel Henrique Bandoni
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Professor, Instituto de Saúde e Sociedade, Universidade Federal de São Paulo. Rua Silva Jardim, 136, Santos, SP, Brasil, 11015-020. Phone +55 (13) 32290100. E-mail: [email protected]
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Sources of funding: This study was supported by the Sao Paulo Research Foundation (Fundação de Amparo a Pesquisa do Estado de São Paulo, FAPESP), n. 15/14881-4, which was awarded to Daniel Henrique Bandoni.
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Conflict of interest: The authors state that there are no conflicts of interest.
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Authors’ contributions: All authors contributed to study conception, statistical analysis and interpretation, manuscript conception, writing, and final revision.
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Ethics Statement: The research project was approved by the National Research Ethics Committee (Registration No. 16,805).
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Highlights
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Brazil implements a national policy requiring public schools to offer meals to students.
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Food consumption between students who eat or not eat meals at school was compared.
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School meal consumption affects positively the overall quality of diet, increases the consumption of healthy diet indicators, and decreases the consumption of unhealthy ones.
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The effect of school feeding programs that offer free meals in school can positively impact on food habits.
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ABSTRACT
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Objective: To analyze the contribution of school meals to the healthy food consumption of public school students in Brazil.
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Methods: The data from the National Adolescent School-Based Health Survey (PeNSE), containing 86,660 ninth-grade students, were used. The students were asked about their consumption of school meals and of food in general over the past seven days and on the day before the interview. A multinomial regression was performed to assess the relationship between the students’ food consumption over the past seven days and regular consumption of school meals (>3 days/week), which were adjusted for sociodemographic factors. Poisson regression models were used for the relationship between food consumed on the day before the interview and regular consumption of school meals.
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Results: Nearly one in five students (22.8%) stated that they consume school meals regularly. The adjusted analyses revealed that the consumption of school meals was associated positively with moderate (3-4 days/week) and regular (>5 days/week) consumption of beans, raw or cooked vegetables, cooked vegetables, and fruits, and with moderate consumption of raw vegetables. In addition, school meal consumption was associated negatively with moderate or regular consumption of fried salty snacks and processed meat, and with regular consumption of packaged salty snacks, crackers, sweet biscuits, and sweets. Based on food consumption on the day preceding the interview, the consumption of school meals significantly affect the consumption of raw and cooked vegetables, and fruits.
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Conclusion: School meal consumption affects positively the consumption of healthy foods and keeps the students from consuming unhealthy foods.
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KEYWORDS: School meals; Food consumption; Adolescent; Food policy; Healthy Diet, Nutritional Requirement.
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Page 2 of 18
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INTRODUCTION
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Adolescence is recognized as an important stage for the development of eating habits, and thus it is a period of nutritional risk [1]. This period of life is considered critical to building a healthy eating pattern, because poor eating habits during childhood and adolescence increase the risk of adult obesity [2,3]. However, a significant growth in the prevalence of obesity is observed globally, including among children and adolescents [4,5].
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In Brazil, compared with adults and the elderly, the dietary intake of adolescents is marked by a lower consumption of beans, vegetables, and salads, and a higher consumption of soft drinks, juices, milk drinks, ice cream, sandwiches, sausages, savory snacks, and packaged food and cookies [6]. According to a national survey in 2012, ninth-grade students reported regular consumption of sweets (41.3%), soft drinks (33.2%), and sweet biscuits (32.5%), aside from fruits (30.2%) [7]. Poor eating habits, such as skipping breakfast and dinner, have also been described [8].
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Given the importance and influence of the environment on food practices, the school environment has been considered strategic in promoting health and healthy eating habits [9,10,11]. Previous studies have shown a consistent positive effect of school feeding programs on energy intake and micronutrient status of school-aged children [12].
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In Brazil, free meals are offered through the Brazilian School Food Program [Programa Nacional de Alimentação Escolar (PNAE)], which started in the 1950s and is one of the largest and successful school feeding programs in the world [13]. To promote healthy eating habits among students, thereby enhancing their development and school performance, this program offers meals during school hours for all students enrolled in public schools throughout the country [14]. Most schools offer one daily meal per student during the period of class. The PNAE guidelines follow the principles that value meals prepared in schools with natural or minimally processed foods and avoid products, such as sugary drinks, sausages, and processed meat [15]. In 2015, the program served meals for 42.6 million students.
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Although the importance of food school environment most of studies have been conducted in the United States and European countries. The present work aims to address this research gap, in the context of the importance of the food school environment and the comprehensive reach of the Brazilian school feeding program. This study compares food consumption between Brazilian students who regularly consume and do not regularly consume meals offered in schools. Thus, considering the impact of healthy eating during childhood and adolescence on adult eating habits, this study aims to analyze the influence of school meals served by the PNAE on food consumption among students enrolled in Brazilian public schools.
Page 3 of 18
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METHODS
118 119
Database and samples
120 121 122 123 124 125
This study used data from the National Adolescent School-based Health Survey (PeNSE) in 2012. The survey was conducted through a partnership between the Brazilian Institute of Geography and Statistics (IBGE) and the Ministry of Health, with support from the Ministry of Education. This study was approved by the National Research Ethics Committee (Registration No. 16,805).
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The PeNSE investigated risk and protective factors concerning the health of adolescents, in a sample of ninth-grade students attending daytime classes at public and private elementary schools, located in urban and rural areas in Brazil. The 2010 School Census was used for sample selection in this study; schools with less than 15 enrollees in academic year 2012were excluded [16].
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The sampling process was different among students living in capital and non-capital cities. Regarding the former, the 26 capitals of States and the Federal District were defined as a geographic stratum (27 strata). A sample of schools was selected in each 27 strata, and in each school, a sample of classes was selected. Regarding the latter, the geographical regions in the North, Northeast, Southeast, South, and Midwest were considered five geographic strata. Schools from each five strata were grouped according to homogeneity and proximity criteria, with groups of about 300 to 600 classes. A sample of these groups was selected from each major region. In both capital and noncapital cities, all students in the selected classes who were present on the day of data collection were asked to answer the survey questionnaire. All participants gave an informed consent [16].
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The PeNSE included 2,842 schools and 4,091 classes. Of the 132,123 students attending these classes, 110,873 were present on the day of data collection, whereas 1,651 opted not to participate and 118 were excluded for not disclosing their age or sex. Therefore, 109,104 students (83%) participated in the survey [16], but the analyses of this study considered only the 86,600 students (82.8%) who were attending public schools.
149 150
Data collection and study variables
151 152 153 154 155 156 157
The data collection was conducted by IBGE from April to September 2012. The analyses of this study used the modules of the questionnaire related to food consumption and sociodemographic characteristics. The survey was self-administered using a smartphone [16]. The students were asked about their food consumption over the last seven days prior to the interview and on the day before the interview. These dietary indicators showed satisfactory validity in research conducted in Brazil [17].
158 159 160 161 162
Regarding food consumption over the past seven days, the students were asked about healthy (beans, raw or cooked vegetables, raw vegetables, cooked vegetables, fruits, and milk) and unhealthy (fried salty snacks, processed meat, crackers, sweet biscuits, packaged salty snacks, sweets, and soft drinks) diet indicators. For each of these foods, the following question was
Page 4 of 18
163 164 165
asked, “WITHIN THE LAST 7 DAYS, on how many days did you eat or drink (name of food or drink)?” The students were divided into three categories based on their responses:
166 167 168
1. Did not consume: This category included students who indicated that they did not consume (name of food or drink) within the past seven days, or that they consumed the item in one to two days of the past seven days.
169 170 171
2. Consumed moderately: This category included students who reported that they had consumed (name of food or drink) in three to four days of the past seven days.
172 173 174
3. Consumed regularly: This category included students who reported that they consumed (name of food or drink) in five to seven days of the past seven days.
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Regarding food consumed on the day before the interview, the dietary intake of raw vegetables, cooked vegetables, and fruits was analyzed by asking the following questions: “Yesterday, in which meals did you eat raw vegetables? Examples: lettuce, tomato, carrot, cucumber, onion, etc.” “Yesterday, in which meals did you eat cooked vegetables, not counting potatoes and cassava (manioc)?” and “Yesterday, how many times did you eat fruit?” The students were divided into two categories based on their responses:
182 183
1. Did not consume: This category included students who indicated that they did not consume the indicated item on the day before the interview.
184 185
2. Consumed: This category included students who consumed the food at least once.
186 187 188 189
The exposure variable of this study was related to the consumption of school meals. Such variable was obtained by asking the following question: “Do you usually eat the meals offered by the school?” For the analyses, responses were grouped into two categories, as indicated in the PeNSE:
190 191 192
1. Do not consume school meals regularly: This category included the responses “My school does not offer meals,” “No, I do not usually eat the meals offered by the school,” “Yes, 1 to 2 days a week,” and “Yes, but seldom.”
193 194
2. Consumes school meals regularly: This category included the responses “Yes, 3 to 4 days a week” and “Yes, every day.”
195 196 197 198 199 200 201 202 203
The following sociodemographic factors were considered: sex, race/color (white, black, mixed, Asian, indigenous), age (grouped into ≤ 13 years, 14 and 15 years, and ≥ 16 years), geographic region (North, Northeast, Southeast, South, Midwest), location of school (capital or non-capital city), living with parents (living with both parents, living with the mother only, living with the father only, or not living with parents), employment status, and maternal education (none, incomplete elementary school, complete elementary school/incomplete high school, complete high school, or some higher education, whether complete or incomplete).
204 205 206 207
As 17.6% (n = 15,265) of the students did not know how to answer the question on maternal education, missing values were obtained through multiple imputations, given that these values were conditioned to other variables [18]. For the imputation, all the variables used in the analysis and those related to
Page 5 of 18
208 209 210 211 212 213 214 215 216 217
income were employed; in addition to outcome (food intake) and exposure (school meals), the authors used sex, race/color, region, location of school, father’s education, living with parents, employment status, household goods (car, landline, mobile phone, and number of bathrooms in the house), services (maid and internet access at home), and the primary sampling units (PSU), because of the complexity of the sample. The multiple imputation by chained equations (MICE) was sequential regression multivariate imputation where all missing values of maternal education are regressed on all other used variables, and the missing values are replaced by simulated draws from the corresponding posterior predictive distribution [18].
218 219
Data analysis
220 221 222 223
For data analysis, the students were characterized according to sociodemographic factors. To evaluate the differences between the students who consumed and did not consume school meals, Pearson’s chi-square tests were performed, and values of p < 0.05 were considered significant.
224 225 226 227 228 229 230 231 232
Association analyses between food consumption within the past seven days prior to the interview (outcome) and regular consumption of school meals (exposure), which were adjusted for sociodemographic characteristics, were performed by multinomial regression with 95% confidence intervals. Analyses on food consumed on the day before the interview (outcome) and consumption of school meals (exposure) were performed by Poisson regression models that generated prevalence ratios, with 95% confidence intervals. The final models included the variables that were associated significantly with food consumption (p < 0.05) or that altered the prevalence ratios by at least 10%.
233 234
For all analyses, the program Stata/SE version 12.1 was used, considering the complex sample design of the survey.
235 236
RESULTS
237 238 239 240 241 242 243 244 245 246
The data from 86,660 ninth-grade students enrolled in public schools were analyzed. Nearly one in five students (22.8%) stated that they consume school meals regularly. Most of them were enrolled in schools located in the Midwest (30.0%) region and few in the Southeast (20.4%) region. Those who reported to consume school meals regularly comprised of 52.5% female and 63.7% male, aged between 14 and 15 years old. Of these students, 14.0% were employed; 56.9% lived with their mother and father; and 79.8% lived in noncapital cities (p < 0.01 in the chi-square test). With respect to maternal education, 34.7% of their mothers did not complete elementary school; 23.7% finished high school; and 10.8% did not study (p < 0.01 in the chi-square test).
247 248 249 250 251 252
A statistically significant difference was found between students who had regular and did not have regular consumption of school meals. A higher consumption of beans, raw or cooked vegetables, raw vegetables, cooked vegetables, and fruits was observed among students who regularly consume and do not regularly consume school meals. Accordingly, a lower consumption of fried salty snacks, processed meat, crackers, sweet biscuits, and sweets was
Page 6 of 18
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observed among those who regularly consume and do not regularly consume school meals regularly (Table 1).
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As shown in Table 2, in there was a statistically significant relationship between the regular consumption of school meals and moderate or regular eating of beans, cooked or raw vegetables, cooked vegetables, and fruits. A higher consumption of these types of food was observed among school children who consumed school meals. Correspondingly, there was a statistically significant relationship between the regular consumption of school meals and the consumption of fried salty snacks, and processed meat,. A lower consumption of these types of food was observed among those who consumed school meals.
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Statistically significant differences were observed in the consumption of raw vegetables, cooked vegetables, and fruit by students on the day before the interview, based on the regularity of consumption of school meals (Table 3). Both in the crude and adjusted models, the regular consumption of school meals was significantly associated with a higher consumption of raw vegetables, cooked vegetables, and fruits on the day before the interview (Table 4).
271 272
DISCUSSION
273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288
The regular consumption of school meals was associated positively with the consumption of healthy foods, and consistently, school meal consumption was associated with a lower consumption of unhealthy foods; these findings suggest that school meals can promote healthy dietary practices among students. Thus, healthy food [19] must be included in the meals served in schools, which must use basic foodstuffs and respect the eating habits, food culture, dietary recommendations, sustainability, and agricultural diversification of the region [20]. The PNAE rules has already imposed a ban on the purchase of sweetened drinks and a restriction on canned foods, processed meat, sweets, compound foods (two or more foods packaged separately for joint consumption), half-finished or ready-made preparations for consumption, and concentrated foods [20]. However, the menus offered in public schools do not always follow the PNAE guidelines. Previous studies have pointed out that certain schools offer limited fruits, vegetables, and variety of foods; they also frequently prepare meals that contain food rich in sugars, fat, and sodium [21,22].
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The importance of food offered in schools has also been observed in other countries, such as the US and France. Among North-American lowincome adolescents, consumption of school meals was associated with a higher intake of fruits and vegetables [23]. In the same way, the results of the third School Nutrition Dietary Assessment Study in the US verified that the consumption of school meals is associated positively with the consumption of fresh fruits, whole grains, and a greater variety of vegetables [24]. In France, in accordance with a national policy, school cafeterias serve students meals that prioritize the supply of healthy foods. As a result, children and adolescents (from 3 to 17 years old) who regularly eat at school cafeterias consume more fruits, fish, and sweet biscuits, or cakes and fewer sandwiches and soft drinks [25]. Although the age range of the students studied is wider than in this study,
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both studies observed a similar finding: school meal favors the consumption of healthy foods, but it does not prevent students from consuming unhealthy foods once these foods are also available at schools.
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This study found that among students who regularly consume school meals, there is a regular consumption of vegetables, beans, and fruits. The ninth-grade students enrolled in public schools in Rio de Janeiro City exhibited a regular consumption (at least five times a week) of beans (83.1%), milk (55%), and fruit (45.8%), however they also consume sweets (46.7%) and soft drinks (36.7%). Meanwhile, a small percentage of these students had a regular consumption of raw (19.9%) or cooked vegetables (16.5%) [26].
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The consumption of fruits and vegetables on the day before the interview was higher among students who reported consuming school meals, which may be attributed to the meal served at the school. In a city in the State of Pernambuco, the daily consumption of fruits and vegetables among adolescents from public schools was investigated; it was found that 10.0% of them did not eat fruits and 30.7% did not eat vegetables, whereas 32.9% ate fruits, 29.9% ate vegetables, and only 6.5% ate both. The consumption of fruit and vegetables was 2.4 times higher among adolescents who ate rice and beans daily [27], which is an example of a food provided in Brazilian school meals.
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In European countries, adolescents were found to consume more potatoes and fewer sweets in school at lunchtime compared with other countries. Although the standards of the school meals may differ among European countries studied, these results, although positive, are limited, suggesting that schools do not seem to use their full potential to provide a healthy meal. In addition, adolescents must be encouraged to stay at school to have lunch and not to look for other places that can offer unhealthy meals [28].
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Considering the PNAE guidelines, food and nutrition education in schools can be a powerful tool for promoting adequate and healthy diet and for improving the consumption of school meals. More importantly, the increased consumption of food offered in schools, together with healthy menus, can impact the promotion of healthy eating habits.
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Offering food at school can improve children’s educational progress, and the role of schools in teaching healthy diet can have an important impact on the food system and health of the population [29,30,31]. The results as this study pointed the positive impact of a school food program, based on a guideline that values natural and minimally processed foods. Because dietary intake is constrained by energy consumption, the offer and consumption of more healthy food in school may reduce the daily consumption of other unhealthy foods [32].
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This study has certain limitations that will be discussed below. The PeNSE was carried out among students who were in their last year of elementary school (ninth grade), which may interfere with the adherence to school meals, as older students appear to have worse acceptance of food offered in schools [33]. The effect observed in the present study could be greater if the younger students were included. This study also did not consider the menu offered in schools, so it is not possible to identify whether the offered meals are responsible for the supply of the healthy foods evaluated. However, based on the PNAE guidelines, it is reasonable to assume that the program has
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an important role in promoting healthy eating. Finally, because of the reference period for data collection of food consumption, it is not possible to say that consuming school meals results in habitual consumption of healthy foods.
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In conclusion, this is the first study that showed the effect of a universal school feeding program in the diet indicators associated with the increase and decrease risk of obesity and chronic diseases. The regular consumption of school meals influences the eating habits of ninth-grade students enrolled in public schools in Brazil, and promotes a healthy diet. The students’ consumption of school meals was associated positively with that of healthy foods. School meal consumption also acts as protection, as it was associated with a lower consumption of unhealthy foods. Strengthening school feeding programs with free meals, and encouraging students to consume these meals can be important tools in promoting healthy eating habits.
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ACKNOWLEDGMENTS
364 365 366
This research was supported by the Sao Paulo Research Foundation (Fundação de Amparo a Pesquisa do Estado de São Paulo, FAPESP), n. 15/14881-4. The support was awarded to Daniel Henrique Bandoni.
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Table 1. Food consumption of students in the last seven days, according to the regular consume school meals. Brazil, 2012. Consume school meals regularly Foods
Yes
No
N
(%)
n
(%)
Did not consume
3,397
16.73
14,547
22.03
Consumed moderately
2,926
14.41
10,825
16.39
Consumed regularly
13,981
68.86
40,675
61.58
Did not consume
8,635
42.56
31,029
47.00
Consumed moderately
4,145
20.43
12,703
19.24
Consumed regularly
7,507
37.00
22,283
33.75
Did not consume
10,994
54.23
38,526
58.38
Consumed moderately
3,480
17.16
10,519
15.94
Consumed regularly
5,800
28.61
16,952
25.69
Did not consume
13,897
68.55
47,803
72.43
Consumed moderately
3,232
15.94
9,387
14.22
Consumed regularly
3,144
15.51
8,809
13.35
Did not consume
9,764
48.18
33,233
50.37
Consumed moderately
4,371
21.57
13,783
20.89
Consumed regularly
6,131
30.25
18,964
28.74
Did not consume
7,533
37.16
24,001
36.36
Consumed moderately
2,896
14.29
8,879
13.45
Consumed regularly
9,843
48.55
33,125
50.19
Did not consume
14,183
69.94
42,792
64.81
Consumed moderately
3,578
17.64
12,743
19.30
Consumed regularly
2,517
12.41
10,493
15.89
Beans**
Raw or cooked vegetables**
Raw vegetables*
Cooked vegetables**
Fruit**
Milk
Fried salty snacks**
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Processed meat** Did not consume
14,492
71.44
44,844
67.94
Consumed moderately
3,318
16.36
12,147
18.40
Consumed regularly
2,475
12.20
9,017
13.66
Did not consume
8,855
43.68
27,620
41.83
Consumed moderately
4,737
23.36
15,183
23.00
Consumed regularly
6,682
32.96
23,221
35.17
Did not consume
10,083
49.79
31,069
47.13
Consumed moderately
4,318
21.32
13,836
20.99
Consumed regularly
5,852
28.89
21,010
31.87
Did not consume
15,424
76.10
48,897
74.10
Consumed moderately
2,618
12.92
8,920
13.52
Consumed regularly
2,226
10.98
8,169
12.38
Did not consume
8,727
43.04
25,989
39.38
Consumed moderately
3,797
18.73
12,398
18.79
Consumed regularly
7,752
38.23
27,602
41.83
Did not consume
7,533
37.16
24,001
36.36
Consumed moderately
2,896
14.29
8,879
13.45
Consumed regularly
9,843
48.55
33,125
50.19
Crackers**
Sweet biscuits**
Packaged salty snacks
Sweets**
Soft drinks
478
*p<0.05 in the chi-square test
479
**p<0.01 in the chi-square test
480 481 482
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483 484 485
Table 2. Multinomial regression results for the association between food consumption in the seven days prior to the interview and the regular consume school meals. Brazil, 2012. Relative Foods
risk,
Relative 95% CI
risk,
crude
adjusted*
1
1
95% CI
Beans Did not consume Consumed moderately
1.16†
1.05 1.29
1.15†
1.04 1.25
Consumed regularly
1.36†
1.16 1.60
1.28†
1.10 1.47
Raw or cooked vegetables Did not consume
1
1
Consumed moderately
1.17†
1.08 1.26
1.16†
1.08 1.26
Consumed regularly
1.17†
1.06 1.29
1.16†
1.05 1.27
Raw vegetables Did not consume
1
1
Consumed moderately
1.09†
1.03 1.15
1.10†
1.04 1.16
Consumed regularly
1.08
0.99 1.17
1.06
0.98 1.15
Cooked vegetables Did not consume
1
1
Consumed moderately
1.26†
1.17 1.35
1.26†
1.17 1.36
Consumed regularly
1.27†
1.20 1.34
1.30†
1.23 1.37
Fruit Did not consume
1
1
Consumed moderately
1.09†
1.04 1.15
1.12†
1.07 1.17
Consumed regularly
1.08†
1.02 1.14
1.07†
1.03 1.12
Milk Did not consume
1
11
Consumed moderately
1.03
0.94 1.13
1.03
0.94 1.12
Consumed regularly
0.94
0.85 1.05
0.93
0.83 1.04
Fried salty snacks Did not consume
1
1
Consumed moderately
0.89†
0.81 0.98
0.89†
0.81 0.97
Consumed regularly
0.71†
0.64 0.79
0.74†
0.63 0.86
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Processed meat Did not consume
1
1
Consumed moderately
0.83†
0.78 0.88
0.83†
0.77 0.88
Consumed regularly
0.88†
0.80 0.97
0.90†
0.83 0.97
Crackers Did not consume
1
1
Consumed moderately
0.80†
0.75 0.86
0.99
0.93 1.05
Consumed regularly
0.90†
0.85 0.97
1.08†
1.01 1.16
Sweet biscuits Did not consume
1
1
Consumed moderately
0.41†
0.36 0.45
0.91
0.80 1.03
Consumed regularly
0.82†
0.73 0.92
0.84†
0.74 0.94
Packaged salty snacks Did not consume
1
1
Consumed moderately
0.92
0.81 1.03
0.92
0.81 1.05
Consumed regularly
0.89†
0.82 0.97
0.91†
0.84 0.98
Sweets Did not consume
1
1
Consumed moderately
0.91†
0.88 0.94
0.95
0.88 1.03
Consumed regularly
0.80†
0.73 0.88
0.84†
0.76 0.93
Soft drinks Did not consume
1
1
Consumed moderately
1.03
0.94 1.13
1.03
0.94 1.12
Consumed regularly
0.94
0.85 1.05
0.93
0.83 1.04
486 487
*Adjusted for the variables: region, capital vs. non-capital cities, sex, race/color, maternal education, age, living with parents, working
488
†
Significant variables (p <0.05) in the Poisson regression model
489
Page 16 of 18
490 491
Table 3. Food consumption of students on the day before the interview, according to the regular consumption of school meals. Brazil, 2012. Consume school meals regularly Consumption Foods
Yes
No
N
(%)
n
(%)
No
9,439
46.51
33,816
51.22
Yes
10,856
53.49
32,199
48.78
No
11,633
57.38
40,281
61.06
Yes
8,641
42.62
25,690
38.94
No
7,694
37.92
26,658
40.38
Yes
12,594
62.08
39,362
59.62
Raw vegetables*
Cooked vegetables*
Fruit*
492
*p<0.01 in the chi-square test
493 494 495
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496 497 498
Table 4. Poisson regression results for the association between food consumption on the day before the interview and the consumption of school meals. Brazil, 2012. Consumption Foods
Prevalence ratio
95% CI
Prevalence ratio
crude
adjusted*
No
1
1
Yes
1.06†
95% CI
Raw salad* 1.02 1.10
1.06†
1.01 1.10
Cooked vegetables No
1
Yes
1.11††
1 1.08 1.13
1.11††
1.08 1.13
Fresh fruit No
1
Yes
1.04†
1 1.02 1.06
1.03†
1.01 1.05
499 500
*Adjusted for the variables: region, capital vs. non-capital cities, sex, race/color, maternal education, age, living with parents, working
501
†
502
††
Significant variables (p <0.05) in the Poisson regression model Significant variables (p <0.001) in the Poisson regression model
503 504 505
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