Adequacy of school menus and national school food program requirements: a systematic review

Abstract Objectives: this review aimed to evaluate the adequacy of school menus regarding the nutritional requirements of the Programa Nacional de Alimentação Escolar (PNAE) in Brazilian public schools regarding the presence of macronutrients and micronutrients and allocation of resources to purchase products from family farming. Methods: a systematic literature review was carried out using the SciELO, Bireme and Lilacs databases to select the articles. The inclusion criteria were articles that presented data on the adequacy of energy, macronutrients, micronutrients, and purchases of products from family farming during the PNAE regiment, as well as quantitative, cross-sectional, and descriptive studies carried out in the Brazilian territory. Review, editorials, letters, case studies, duplicates and those that did not assess the requirements of the PNAE were excluded. Results: at the end, 12 studies were included that showed overestimation and underestimation of nutritional adequacy in the school environment. In relation to purchases of inputs from family farming, it was observed that most of the Brazilian municipalities evaluated fulfilled the requirements for the allocation of resources. Conclusion: school menus need more supervision so that they meet the adjustments proposed by the PNAE. In addition, it is essential to promote a healthy diet that contains all the nutrients necessary to provide nutritional support for child growth and development.


Introduction
Changes in the current lifestyle have promoted the adoption of eating practices that can contribute to the increase in overweight and obesity, especially in childhood. 1In addition, social, economic and cultural changes also influenced the establishment of habits and behaviors, including the increase in consumption of ultra-processed foods (UPF) with a high concentration of energy, fat, sugar and sodium.Associated with this, there is a decrease in the intake of in natura foods such as cereals, legumes, fruits, vegetables and legumes. 2 This change in food intake has occurred more frequently in the early stages of life, such as childhood. 3A study that evaluated the food consumption of schoolchildren based on the National School Health Survey observed a daily consumption of 42.8% UPF among Brazilian adolescents. 4he school food environment should be a place to promote healthy eating habits, with a positive impact on the child's growth and development process. 5Inadequate nutrition in these stages of life can generate nutritional deficiencies and contribute to the appearance of Chronic Noncommunicable Diseases (NCDs), including obesity in adulthood. 6Evidence shows that severe changes in nutritional status and nutrient intake can impair school performance due to changes in brain development and memory capacity. 7In this way, school meals must be of appropriate quality and quantity, with the purpose of ensuring the essential nutritional needs, promoting adequate development and healthy eating habits. 6he National School Feeding Program (PNAE) aims to provide healthy meals, food and nutrition education actions to promote biopsychosocial growth, better school performance and healthy eating practices during the school period. 8In a study that evaluated the execution of the PNAE, it was observed that most problems were related to the reduction in acquisition of food from family farming and in the nutritional composition of the menus. 9he requirements of the PNAE are current strategies to reduce the prevalence of food and nutrition insecurity and hunger. 10These actions directly cause growth in the household income of residents under the age of eighteen and rural workers. 11hus, it is important to observe the implementation of nutritional and food requirements determined by the PNAE and to evaluate the adequacy of school menus regarding the purchase of products from family farming and the adequacy of nutrients.In addition, it is not clear how school menus are adapted and monitored in terms of PNAE requirements.Therefore, the aim of this systematic review was to evaluate the adequacy of school menus regarding the nutritional requirements of the PNAE in public schools in the national territory, considering the adequacy of macronutrients and micronutrients and allocation of resources for purchases of products from family farming.

Methods
This is a systematic review of the literature, from which searches were carried out in original scientific articles that evaluated the recommendations required by the PNAE regarding nutritional adequacy in school menus.This review followed the recommendations of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). 12o carry out the searches, the following keywords were used based on Health Sciences Descriptors (DECS), forming the following equation: Alimentação AND escolas públicas.The articles were selected through the bases Scientific Electronic Library (SciELO), Latin American and Caribbean Literature on Health Sciences (Lilacs) and Regional Library of Medicine (Bireme).The searches were carried out in August/2022 by two independent researchers and discrepancies were resolved with the help of a third author.The agreement between the authors was evaluated using the Kappa coefficient (k=0.089,p=0.542).
For the inclusion criteria, studies that evaluated food according to the nutritional requirements of the PNAE in relation to the adequacy of calories, macronutrients (proteins, carbohydrates, and lipids), micronutrients (vitamin A and C, calcium, iron and sodium) and/or or purchase of products from family farming.In addition, quantitative, cross-sectional, and descriptive studies carried out in Brazil were included.Review articles, case studies, articles in duplicates and articles that did not assess the requirements of the PNAE were excluded.There was no distinction regarding language and year of publication.
All articles that met the eligibility criteria were evaluated in terms of title and abstract.Those for which it was not possible to identify their inclusion by title and abstract were evaluated for the full text.
After reading the included articles, data extraction was performed by two independent authors.Disagreements were discussed to reach a consensus.For the preparation of the qualitative synthesis, data were selected on: Author and year of publication, sample, type of study, method of evaluating the requirements of the PNAE, variables studied and results regarding the requirements of the PNAE.

Results
In total, 1020 studies (Bireme: 603/ SciELO: 94/ Lilacs: 323) were selected in the databases.After Reading the titles, abstracts and full text, 186 duplicates were excluded using ENDNOTE® software.834 articles were also excluded due to the reason that they were review articles, case studies, duplicates and articles that did not evaluate the subject.Finally, 12 studies that met eligibility criteria were included (Figure 1).][19][20][21][22][23][24] Of the selected studies, most were published between 2018 and 2019 (n=7).The studies used a sample of PNAE students and managers.Most studies were carried out in the South (Paraná, Santa Catarina and Rio Grande do Sul) and Southeast (Minas Gerais, Rio de Janeiro, and São Paulo) regions (Table 1).Of the studies that evaluated the adequacy of menus, all were carried out in public, municipal or state schools, in different age groups, from nursery to Youth and Adult Education (EJA -Portuguese acronym).The menus were evaluated through quantitative analysis and direct weighing of the foods.The description of the studies and the adequacy results are shown in Table 2.
The adequacy of energy (kcal) and macronutrients was investigated in four studies.Studies that observed inadequacy of energy, carbohydrates and lipids observed that menus were above (>110%) or below (<110%) the recommendation.Only the study by carried out by Araújo et al., 13 observed adequacy of protein recommendations.About micronutrients, inadequacy of vitamin A C, calcium and iron was observed in most of the institutions that evaluated inadequacy.Regarding sodium levels, only one study evaluated its adequacy, observing high consumption in preschool (four to five years), Elementary I (6 to 10 years) and II (11 to 15 years) and high school (16 years).to 18 years).The percentage of inadequacy varied between 101.8% and 191.9%. 15he acquisition of products from family farming was investigated in eight studies as described in Table 3. [17][18][19][20][21][22][23][24] The investigation of the purchase of products from family farming was evaluated in different municipalities.Of the eight studies evaluated, five revealed that the investigated municipalities used at least 30% of the resources transferred by the FNDE to purchase products from family farming.17,18,20,23,25

Figure 1
Study selection flowchart.

Table 1
Description of the studies selected regarding the sample, place of execution and executing institution of the PNAE.

Characteristics of the menus Evaluation method
Araujo et al., 13

Table 2
Description of the selected studies and results regarding the adequacy of school menus regarding the nutritional requirements of the PNAE.

Table 3
Description of the results regarding the purchase of food from family farming for the composition of school menus regarding the requirements of the PNAE.

Author, year Place of execution Purchasing information source Purchase of products from family farming
Dias et al., 17  In Machado et al. 25 several Brazilian municipalities in all regions (North, Northeast, South and Midwest) purchased products from family farming and only those in the Southeast region did not reach the 30% required by the PNAE.In addition, in one of the studies it was observed that the allocation of resources occurred below the requirements (29.5%). 22However, the percentage of purchase from family farming met the recommendations of the PNAE.In another study, it was observed that no resources were allocated to purchases of food from family farming. 24

Discussion
This systematic review evaluated the adequacy of school menus in terms of PNAE requirements for the nutritional adequacy of macro and micronutrients, in addition to the allocation of resources from the purchase of food from family farming.It was possible to observe that the requirements of the PNAE for nutritional adequacy were not met for most of the evaluated nutrients, as well as the allocation of resources for the purchase of family farming inputs does not occur in all municipalities, in which the resource is transferred.
According to the PNAE, recommendations for nutritional adequacy for daycare centers should be 70% of total energy needs in full-time schools and 30% of needs for part-time students, considering variations of 10% above or below 100 % of recommendations. 14For basic education, recommendations should be 20% of nutritional requirements for one meal and 30% for two or more meals. 26For students enrolled in full-time schools, nutritional needs must meet 70% of food intake spread over at least three meals.Nutritional adjustments must meet the closest values recommended by Article 18 of the Resolution of the Deliberative Council of the National Education Development Fund (CD/FNDE -Portuguese acronym) No. 06, of May 8, 2020.
The PNAE has norms to establish and ensure good nutrition for students and organization regarding financial resources.The adequacy of reference values is an important factor that will contribute to the supply of nutrients to students during their time at school. 10 The supply of daily energy needs should seek to achieve nutritional goals that can avoid deficiencies or excess consumption of energy and nutrients, also preventing the emergence of nutritional disorders such as obesity or malnutrition. 27Therefore, the PNAE acts as a guarantee mechanism for Food and Nutrition Security.
It is known that during childhood, adequate energy supply is necessary in sufficient quantity to provide nutrients for the processes of cellular hypertrophy and hyperplasia. 28Food during childhood is an important factor for development and growth, and may help prevent diseases that may develop in adulthood. 29Thus, the school environment exerts great influence on the establishment of eating habits in childhood. 30ell-nourished children reach their full potential for growth and development and some micronutrients are essential at this stage.Iron, for example, is essential for cognitive development.Prevention of iron deficiency in childhood is carried out through supplementation and increased intake of iron-rich foods in the diet. 31 cohort that investigated the long-term effects of iron deficiency observed that, at age 19, young people who were iron deficient as children performed less well on a recognition memory test when compared to those without iron deficiency in early life. 32 cohort that investigated the long-term effects of iron deficiency observed that, at age 19, young people who were iron deficient as children performed less well on a recognition memory test when compared to those without iron deficiency in early life. 33In the study of Leão et al., 15 sodium inadequacies ranging from 85.1% to 191.9% were observed.A study carried out with Brazilian preschool children observed that those with sodium intake greater than 1,200 mg/day have 3.32 (CI95%=0.98-11.22)times more likely to have high systolic blood pressure.The authors suggested that the main source of this micronutrient came from UPFs, since the salt added to the preparations was not evaluated. 34n Resolution No. 06/2020, a maximum of 20% of PNAE resources can be used to purchase UPFs, such as refreshments, canned goods and sausages.It is possible that the inadequacies observed in the present review are due to the increase in the purchase and supply of ultraprocessed foods, since they are negatively associated with the consumption of iron, zinc, phosphorus, magnesium, proteins, fibers, potassium and vitamins B12, C and E , and positively associated with the energy density of Brazilian diets. 35hen the purchase of food occurs primarily through the PNAE, there is a greater purchase of fresh and minimally processed foods.In a descriptive cross-sectional study that evaluated the degree of food processing obtained through the PNAE in three municipalities in southern Brazil, it was observed that there were greater purchases of in natura and minimally processed foods, which represented 49.8% of the total energy purchased.It should be noted that, among the acquisitions of family farming evaluated in the study, 51.3% of the total energy purchased came from in natura and minimally processed foods. 36Thus, there is an importance of family farming to strengthen healthy eating habits in the school environment.In addition, it contributes to an adequate diet in qualitative and quantitative terms.review of the manuscript.Fernandes MSS: research design, data analysis, critical review of the manuscript.Ribeiro IC: data collection and analysis, interpretation of results, writing and critical review of the manuscript.Oliveira TLPSA: data collection, analysis, and interpretation of results, writing and critical review of the manuscript.Silva JA: research design and design, data collection, analysis, and interpretation of results, writing and critical review of the manuscript.The authors approved the final version of the article and declare that there is no conflict of interest.However, there are still regions that do not reach the purchase percentage required by the PNAE.As required by the PNAE, the purchase of food from family farming must be 30% of total purchases. 13Family farming is of great importance for school meals, as a way to strengthen local agriculture.The inclusion of products from family farming in school meals is an action that promotes food and nutritional security.Family farming respects biodiversity, food autonomy and environmental sustainability. 37hus, like the PNAE, the food acquisition program (PAA -Portuguese acronym) uses family farming as a way of encouraging the sale of local products and promoting access to adequate and healthy food. 38In addition, it allows for a more sustainable food grouping, bringing together producers and consumers in order to improve the habits and food culture of each place. 39Therefore, the FNDE, together with the PNAE, plays an important role in the mediation process between farmers and the public authorities, acting in the negotiation of menus, prices, among other items.
This review has limitations.Among them, only one study estimated the adequacy of sodium and only one study carried out direct weighing of foods, limiting the observation regarding the seasonality of foods.However, three large databases were consulted to identify the studies included in the review, making it possible to assess the adequacy of menus served for different age groups and regions of Brazil.In addition, this study draws attention to the need to evaluate the menus that are being served to schools, as well as purchases for their implementation, especially in scenarios of dismantling social public policies.Furthermore, it was possible to observe the interconnection between nutritional aspects and political, economic, and social aspects.

Final considerations
The nutritional requirements according to the PNAE were not followed, when the nutritional adequacy is an allocation of resources above 30% for the purchase of products from family farming.Thus, it is observed that there is a need in relation to the adequacy of menus for a better nutritional supply that provides adequate nutrients for school performance, growth, and human development.In addition, the need for regulatory bodies to supervise the execution of the PNAE in the municipalities is reinforced, given its importance in combating food and nutritional insecurity.

Authors' contribution
Santos GCJ: research design and design, data collection, analysis, and interpretation of results, writing and critical