Programa Cantinas Escolares Saudáveis e Seguras
um estudo controlado randomizado
Palavras-chave:
Educação alimentar e nutricional, Política nutricional, Alimentação escolar, Serviços de saúde escolar, LanchesResumo
Objetivo
Avaliar o efeito de um programa de intervenção educacional nas condições de risco à saúde com base na avaliação das condições higiênicas e na qualidade dos alimentos comercializados em cantinas escolares.
Métodos
Este é um estudo comunitário, controlado, paralelo, randomizado, dois braços. As escolas de Ensino Fundamental e Médio, públicas e privadas, que possuíam cantinas, foram convidadas a participar. Este estudo foi realizado em 27 cantinas escolares do norte e noroeste do Rio Grande do Sul, sul do Brasil. Representantes da comunidade escolar das cantinas do grupo intervenção receberam um programa educacional composto por um treinamento a distância de 160 horas. Os principais desfechos avaliados foram avaliação das condições higiênicas e composição dos alimentos vendidos nas cantinas escolares. Todos os resultados foram analisados como intenção de tratar e per protocolo. Para análise dos dados contínuos, com distribuição normal, utilizou-se a análise de covariância e o Modelo Linear Generalizado. O nível de significância estatística considerado foi p<0,05 para um intervalo de confiança de 95%.
Resultados
Não foi observada diferença estatisticamente significativa entre o grupo intervenção e o grupo controle nos desfechos estudados. Houve redução de 76,2 pontos no escore das condições higiênicas de manipulação (IC 95%: -205 a 357; p=0,581). Em relação à composição dos cardápios, a diferença entre os grupos foi de 0,48% (IC 95%: -2,69 a 3,64; p=0,760) para os alimentos ultraprocessados, 0,23% (IC 95%: -1,13 a 1,60; p=0,740) para os alimentos processados e 1,02% (IC 95%: -2,59 a 4,64; p=0,581) para os alimentos in natura.
Conclusão
Não há evidências suficientes para concluir que a intervenção teve impacto positivo em nenhum dos desfechos estudados.
Referências
Malta DC, Felisbino-Mendes MS, Machado ÍE, Passos VMA, Abreu DMX, Ishitani LH, et al. Fatores de risco relacionados à carga global de doença do Brasil e Unidades Federadas, 2015. Rev Bras Epidemiol. 2017;217-32. https://doi.org/10.1590/1980-5497201700050018
Pelegrini A, Bim MA, Souza FU, Kilim KSS, Pinto AA. Prevalence of overweight and obesity in Brazilian children and adolescents: a systematic review. Rev Bras Cineantropom. 2021;23:e80352. https://doi.org/10.1590/1980- 0037.2021v23e80352
Zarei N, Ahmadi A. Nutrition Transition: an intergenerational comparison of dietary habits among women of shiraz. Iran J Public Health. 2015 [cited 2020 Apr 9];44(2):269-75. Available from: https://pubmed.ncbi.nlm.nih. gov/25905062
Santiago-Torres M, Adams AK, Carrel AL, LaRowe TL, Schoeller DA. Home food availability, parental dietary intake, and familial eating habits influence the diet quality of urban Hispanic children. Child Obes. 2014;10(5):408-15. https://doi.org/10.1089/chi.2014.0051
Institute for Health Metrics and Evaluation. Global burden of disease data. Institute for Health Metrics and Evaluation. Seattle; 2015 [cited 2020 Sep 8]. Available from: http://www.healthdata.org/gbd/data
World Health Organization. Report of the Commission on Ending Childhood Obesity. Geneva: Organization; 2016 [cited 2020 Mar 2]. Available from: http://www.who.int/end-childhood-obesity/publications/echo-report/en/
Singh A, Bassi S, Nazar GP, Saluja K, Park M, Kinra S, et al. Impact of school policies on non-communicable disease risk factors: a systematic review. BMC Public Health. 2017;17(1):292. https://doi.org/10.1186/s12889-017-4201-3
Foster GD, Sherman S, Borradaile KE, Grundy KM, Vander Veur SS, Nachmani J, et al. A policy-based school intervention to prevent overweight and obesity. Pediatrics. 2008;121(4):e794-802. https://doi.org/10.1542/ peds.2007-1365
World Health Organization. School policy framework: implementation of the WHO global strategy on diet, physical activity and health. Genebra: Organization; 2008 [cited 2020 Sep 8]. Available from: https://apps.who.int/iris/ handle/10665/43923
Yoong SL, Nathan NK, Wyse RJ, Preece SJ, Williams CM, Sutherland RL, et al. Assessment of the school nutrition environment: a study in Australian primary school canteens. Am J Prev Med. 2015;49(2):215-22. https://doi. org/10.1016/j.amepre.2015.02.002
Chriqui J, Resnick E, Schneider L, Schermbeck R, Adcock T, Carrion V, et al. School District Wellness Policies: evaluating progress and potential for improving children’s health five years after the federal mandate. Chicago: Institute for Health Research and Policy; 2013 [cited 2020 Sep 8]. Available from: https://eric.ed.gov/?id=ED540415
Wolfenden L, Nathan N, Janssen L, Wiggers J, Reilly K, Delaney T, et al. Multi-strategic intervention to enhance implementation of healthy canteen policy: a randomised controlled trial. Implement Sci. 2017;12(1):6. http://dx.doi. org/10.1186/s13012-016-0537-9
Fox MK, Gordon A, Nogales R, Wilson A. Availability and consumption of competitive foods in us public schools. J Am Diet Assoc. 2009;109(2):S57-66. https://doi.org/10.1016/j.jada.2008.10.063
Nathan N, Yoong SL, Sutherland R, Reilly K, Delaney T, Janssen L, et al. Effectiveness of a multicomponent intervention to enhance implementation of a healthy canteen policy in Australian primary schools: a randomised controlled trial. Int J Behav Nutr Phys Act. 2016;13(1):106. http://dx.doi.org/10.1186/s12966-016-0431-5
Gabriel CG, Vasconcelos FDAG, Andrade DF, Schmitz BAS. First Law regulating school canteens in Brazil: evaluation after seven years of implementation. Arch Latinoam Nutr. 2009 [cited 2020 May 8];59(2):128-38. Available from: http://ve.scielo.org/scielo.php?pid=S0004-06222009000200003&script=sci_abstract&tlng=en
Wognski ACP, Ponchek VL, Dibas EES, Orso MR, Vieira LP, Ferreira BGCS, et al. Comercialização de alimentos em cantinas no âmbito escolar. Brazilian J Food Technol. 2019;22:1-12. https://doi.org/10.1590/1981-6723.19818
Lawlis T, Knox M, Jamieson M. School canteens: a systematic review of the policy, perceptions and use from an Australian perspective. Nutr Diet. 2016;73(4):389-98. http://doi.wiley.com/10.1111/1747-0080.12279
O’Halloran S, Eksteen G, Gebremariam M, Alston L. Measurement methods used to assess the school food environment: a systematic review. Int J Environ Res Public Health. 2020;17(5):14-22. https://doi.org/10.1186/ s12966-017-0477-z
Finch M, Sutherland R, Harrison M, Collins C. Canteen purchasing practices of year 1-6 primary school children and association with SES and weight status. Aust N Z J Public Health. 2006;30(3):247-51. http://dx.doi.org/10.1111/ j.1467-842X.2006.tb00865.x
Santana MO, Guimarães JS, Leite FHM, Mais LA, Horta PM, Bortoletto Martins AP, et al. Analysing persuasive marketing of ultra-processed foods on Brazilian television. Int J Public Health. 2020;65(7):1067-77. https://doi. org/10.1007/s00038-020-01456-6
Clinton-McHarg T, Janssen L, Delaney T, Reilly K, Regan T, Nathan N, et al. Availability of food and beverage items on school canteen menus and association with items purchased by children of primary-school age. Public Health Nutr. 2018;21(15):2907-14. https://doi.org/10.1017/S1368980018001726
Peres CMC, Gardone DS, Costa BVL, Duarte CK, Pessoa MC, Mendes LL. Retail food environment around schools and overweight: a systematic review. Nutr Rev. 2020;78(10):841-56. https://doi.org/10.1093/nutrit/nuz110
Marinho GA, Oliveiraa GS, Lima JL, Lopes WMA, Nunes GA, Nunes MGA. Perfil epidemiológico das doenças transmitidas por alimentos e seus fatores causais na região da Zona da Mata Sul de Pernambuco. Cient Ciênc Biol Saúde. 2015;17:238-48.
Food and Agriculture Organization of the United Nations. FAO School Food and Nutrition Framework. Roma: Organization; 2019 [cited 2020 Oct 10]. Available from: http://www.fao.org/3/ca4091en/ca4091en.pdf
Danelon MAS, Danelon MS, Silva MV. Serviços de alimentação destinados ao público escolar: análise da convivência do Programa de Alimentação Escolar e das cantinas. Seg Aliment Nutr. 2006;1:85-94. https://doi.org/10.20396/ SAN.V13I1.1847
Sturion GL, Silva MV, Ometto AMH, Furtuoso MCO, Pipitone MAP. Fatores condicionantes da adesão dos alunos ao Programa de Alimentação Escolar no Brasil. Rev Nutr. 2005;18:167-81. https://doi.org/10.1590/0102-311X00061016
Souza LBO, Azevedo ABC, Henrique D, Bandoni, Canella DS. Características do ambiente escolar relativas à alimentação e atividade física: PeNSE 2015. Rev Saude Publica. 2021;55:e115. https://doi.org/10.11606/s1518- 8787.2021055003377
Carmo AS, Assis MM, Cunha CF, Oliveira TRPR, Mendes LL. The food environment of Brazilian public and private schools. Cad Saude Publica. 2018;34:e00014918. https://doi.org/10.1590/0102-311x00014918
Billich N, Adderley M, Ford L, Keeton I, Palermo C, Peeters A, et al. The relative price of healthy and less healthy foods available in Australian school canteens. Health Promot Int. 2018;34(4):677-86. https://doi.org/10.1093/ heapro/day025
World Health Organization. Nutrition action in schools: a review of the evidence related to the nutrition-friendly schools initiative. Geneve: Organization; 2020. Available from: https://www.who.int/publications/i/item/9789241516969
Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, et al. CONSORT 2010 Explanation and Elaboration: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340:c869. https://doi. org/10.1136/bmj.c869
Chan A-W, Tetzlaff JM, Gøtzsche PC, Altman DG, Mann H, Berlin JA, et al. SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials. BMJ. 2013;346:e7586. https://doi.org/10.1136/bmj.e7586
Balestrin M, Brasil CCB, Bellei EA, Kirsten VR, Wagner MB. Program for healthier school cafeterias in Rio Grande do Sul, Brazil: protocol for a community-based randomized trial. JMIR Res Protoc. 2021;10(1):e22680. https://doi. org/10.2196/22680
Deckert CT. A Gestão social no território da cidadania noroeste colonial do Rio Grande do Sul [dissertation]. Ijuí: Universidade Regional do Noroeste do Estado do Rio Grande do Sul; 2012 [cited 2020 Aug 5]. Available from: http:// bibliodigital.unijui.edu.br:8080/xmlui/handle/123456789/1906
Deckert CT, Allebrandt SL. A efetividade da cidadania no programa Territórios da Cidadania: um estudo de caso do noroeste colonial do Rio Grande do Sul. Amaz Organ Sustentabilidade. 2013;2(2):8238-8893. http://dx.doi. org/10.17800/2238-8893/aos.v2n2p139-152
Deckert CT. Configuração do poder no Codeter: uma análise do Território da Cidadania Noroeste Colonial-RS. Redes. 2017;22(1):402-29. https://doi.org/10.17058/redes.v22i1.5259
Nathan N, Yoong SL, Sutherland R, Reilly K, Delaney T, Janssen L, et al. Effectiveness of a multicomponent intervention to enhance implementation of a healthy canteen policy in Australian primary schools: a randomised controlled trial. Int J Behav Nutr Phys Act. 2016;13(1):c106. http://dx.doi.org/10.1186/s12966-016-0431-5
Ministério da Saúde (Brasil). Manual das cantinas escolares saudáveis: promovendo a alimentação saudável. Brasília: Ministerio; 2010.
Rio Grande do Sul. Lei no 15.216, de 30 de julho de 2018. Dispõe sobre a promoção da alimentação saudável e proíbe a comercialização de produtos que colaborem para a obesidade, diabetes, hipertensão, em cantinas e similares instalados em escolas públicas e privadas do Estado do Rio Grande do Sul. Porto Alegre: Governo do Estado; 2018 [cited 2020 Aug 5]. Available from: https://leisestaduais.com.br/rs/lei-ordinaria-n-15216-2018-rio-grande-do-sul-dispoe-sobre-a-promocao-da-alimentacao-saudavel-e-proibe-a-comercializacao-de-produtos-que-colaborem-para-a-obesidade-diabetes-hipertensao-em-cantinas-e-similares-instalados-em-e
Ministério da Sáide (Brasil). Guia alimentar para a população brasileira. Brasília: Ministério; 2014.
Ministério da Saúde (Brasil). Guia alimentar para a população brasileira: versão resumida. Brasil: Ministério; 2018.
Giacomelli SC. Avaliação e promoção de boas práticas em cantinas escolares [dissertation]. Santa Maria: Universidade Federal de Santa Maria; 2014 [cited 2020 Jul 8]. Available from: https://repositorio.ufsm.br/handle/1/5763
Porto E. Perfil das cantinas escolares do Distrito Federal [dissertation]. Brasília: Universidade de Brasília; 2011 [cited 2020 Aug 9]. Available from: https://repositorio.unb.br/handle/10482/10036
Agência Nacional de Vigilância Sanitária. Categorização dos serviços de alimentação: elaboração e avalição da lista de avaliação. Brasília: Agência; 2013.
Cunha DT, Saccol ALF, Tondo EC, Oliveira ABA, Ginani VC, Araújo CV, et al. Inspection score and grading system for food services in Brazil: the results of a food safety strategy to reduce the risk of foodborne diseases during the 2014 FIFA World Cup. Front. Microbiol. 2016;7:e614. https://doi.org/10.3389/fmicb.2016.00614
Cunha DT, Oliveira ABA, Saccol ALF, Tondo EC, Silva EA, Ginani VC, et al. Food safety of food services within the destinations of the 2014 FIFA World Cup in Brazil: development and reliability assessment of the official evaluation instrument. Food Res Int. 2014;57:95-103. https://doi.org/10.1016/j.foodres.2014.01.021
Agência Nacional de Vigilância Sanitária. Categorização dos serviços de alimentação: elaboração e avalição da lista de avaliação. Brasília: Agência; 2013.
Ministério da Saúde (Brasil). Portaria no 817, de 10 de maio de 2013. Aprova as diretrizes nacionais para a elaboração e execução do projeto-piloto de categorização dos serviços de alimentação para a Copa do Mundo FIFA 2014. Brasília: Ministério; 2013 [cited 2020 Aug 5]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/ prt0817_10_05_2013.html
Verdum DCP, Selva JP, Copatti F, Batista M, Pereira LS, Kirsten VR, et al. Condições higiênico-sanitárias das cantinas escolares da rede estadual de ensino no município de Palmeira das Missões, Rio Grande do Sul. Vigil Sanit Debate. 2017;5(4):17-23. https://doi.org/10.22239/2317-269x.00960
Monteiro CA, Levy RB, Claro RM, Castro IRR, Cannon G. A new classification of foods based on the extent and purpose of their processing. Cad Saude Publica. 2010;26(11):2039-49. https://doi.org/10.1590/S0102- 311X2010001100005
Williams CM, Nathan N, Delaney T, Yoong SL, Wiggers J, Preece S, et al. CAFE: a multicomponent audit and feedback intervention to improve implementation of healthy food policy in primary school canteens: protocol of a randomised controlled trial. BMJ Open. 2015;5(6):e006969. http://dx.doi.org/10.1136/bmjopen-2014-006969
Wolfenden L, Nathan N, Williams CM, Delaney T, Reilly KL, Freund M, et al. A randomised controlled trial of an intervention to increase the implementation of a healthy canteen policy in Australian primary schools: study protocol. Implement Sci. 2014;9:147. https://doi.org/10.1186/s13012-014-0147-3
Rio Grande do Sul. Decreto no 54.994, de 17 de janeiro de 2020. Regulamenta a Lei nº 15.216, de 30 de julho de 2018, que dispõe sobre a promoção da alimentação saudável e proíbe a comercialização de produtos que colaborem para a obesidade, diabetes e hipertensão em cantinas e similares instalados em escolas públicas e privadas do Estado do Rio Grande do Sul. Porto Alegre: Governo do Estado; 2020 [cited 2020 Aug 5]. Available from: http://www.al.rs. gov.br/filerepository/repLegis/arquivos/DEC 54.994.pdf
Rio Grande do Sul. Lei no 13.027, de 16 de agosto de 2008. Dispõe sobre a comercialização de lanches e de bebidas em escolas no âmbito do estado do Rio Grande do Sul e dá outras providências. Porto Alegre: Governo do Estado; 2008 [cited 2020 Aug 5]. Available from: https://leisestaduais.com.br/rs/lei-ordinaria-n-13027-2008-rio-grande-do-sul-dispoe-sobre-a-comercializacao-de-lanches-e-de-bebidas-em-escolas-no-ambito-do-estado-do-rio-grande-do-sul-e-da-outras-providencias
Horta RL, Andersen CS, Pinto RO, Horta BL, Oliveira-Campos M, Andreazzi MAR, et al. Health promotion in school environment in Brazil. Rev Saude Publica. 2017;51:e06709. https://doi.org/10.1590/s1518-8787.2017051006709
Clayton ML, Clegg Smith K, Neff RA, Pollack KM, Ensminger M. Listening to food workers: Factors that impact proper health and hygiene practice in food service. Int J Occup Environ Health. 2015;21(4):314-27. https://doi.org/ 10.1179/2049396715Y.0000000011
Green L, Selman C, Banerjee A, Marcus R, Medus C, Angulo FJ, et al. Food service workers’ self-reported food preparation practices: an EHS-Net study. Int J Hyg Environ Health. 2005;208(1-2):27-35. https://doi.org/10.1016/j. ijheh.2005.01.005
Ricke SC, Donaldson JR, Phillips CA. Food safety emerging issues, technologies, and systems. Cambridge: Academic Press; 2015.
Freitas RSG, Cunha DT, Stedefeldt E. Food safety knowledge as gateway to cognitive illusions of food handlers and the different degrees of risk perception. Food Res Int. 2019;116:126-34. https://doi.org/10.1016/j.foodres.2018.12.058
Cunha DT, Rosso VV, Stedefeldt E. Food safety performance and risk of food services from different natures and the role of nutritionist as food safety leader. Cien Saude Colet. 2018;23:4033-42. https://doi.org/10.1590/1413- 812320182312.21042016
Madeira M, Ferrão MEM. Alimentos conforme a lei. São Paulo: Manole; 2002.
Yoong SL, Nathan N, Wolfenden L, Wiggers J, Reilly K, Oldmeadow C, et al. CAFE: a multicomponent audit and feedback intervention to improve implementation of healthy food policy in primary school canteens: a randomised controlled trial. Int J Behav Nutr Phys Act. 2016;13(1):126. http://dx.doi.org/10.1136/bmjopen-2014-006969
Reilly K, Nathan N, Wiggers J, Yoong SL, Wolfenden L. Scale up of a multi-strategic intervention to increase implementation of a school healthy canteen policy: findings of an intervention trial. BMC Public Health. 2018;18(1):860. https://doi.org/10.1186/s12889-018-5786-x
Evenhuis IJ, Jacobs SM, Vyth EL, Veldhuis L, Boer MR, Seidell JC, et al. The effect of supportive implementation of healthier canteen guidelines on changes in dutch school canteens and student purchase behaviour. Nutrients. 2020;12(8):2419. https://doi.org/10.3390/nu12082419
Reilly K, Nathan N, Wu JHY, Delaney T, Wyse R, Cobcroft M, et al. Assessing the potential impact of a front-of-pack nutritional rating system on food availability in school canteens: a randomised controlled trial. Appetite. 2018;121:309-15. https://doi.org/10.1016/j.appet.2017.11.103
Maia EG, Passos CM, Levy RB, Bortoletto Martins AP, Mais LA, Claro RM. What to expect from the price of healthy and unhealthy foods over time? The case from Brazil. Public Health Nutr. 2020;23(4):579-88. https://doi.org/10.1017/ S1368980019003586
O’Halloran S, Lacy K, Woods J, Grimes CA, Campbell KJ, Nowson CA. The provision of ultra-processed foods and their contribution to sodium availability in Australian long day care centres. Public Health Nutr. 2018;21(1):134-41. https://doi.org/10.1017/S136898001700132X
Azeredo CM, Rezende LFM, Canella DS, Claro RM, Peres MFT, Luiz OC, et al. Food environments in schools and in the immediate vicinity are associated with unhealthy food consumption among Brazilian adolescents. Prev Med. 2016;88:73-9. https://doi.org/10.1016/j.ypmed.2016.03.026
Khandpur N, Neri DA, Monteiro C, Mazur A, Frelut M-L, Boyland E, et al. Ultra-Processed food consumption among the paediatric population: an overview and call to action from the European childhood obesity group. Ann Nutr Metab. 2020;76(2):109-113. https://doi.org/10.1159/000507840 Austin EW, Austin B, Kaiser CK, Edwards Z, Parker L, Power TG. A Media literacy-based nutrition program fosters parent–child food marketing discussions, improves home food environment, and youth consumption of fruits and vegetables. Child Obes. 2020;16(S1):S-33-43. https://doi.org/10.1089/chi.2019.0240
Sing F, Mackay S, Culpin A, Hughes S, Swinburn B. Food Advertising to Children in New Zealand: a Critical Review of the Performance of a Self-Regulatory Complaints System Using a Public Health Law Framework. Nutrients. 2020;12(5):1278. https://doi.org/10.3390/nu12051278
Yee AZH, Lwin MO, Ho SS. The influence of parental practices on child promotive and preventive food consumption behaviors: a systematic review and meta-analysis. Int J Behav Nutr Phys Act. 2017;14(1):47. https://doi.org/10.1186/ s12966-017-0501-3
Bezerra JAB. Educação alimetar e nutricional: articulação de saberes. Fortaleza: Edições UFC; 2018.
Arcan C, Kubik MY, Fulkerson JA, Davey C, Story M. Association between food opportunities during the school day and selected dietary behaviors of alternative high school students, Minneapolis/Saint Paul, Minnesota, 2006. Prev Chronic Dis. 2011 Jan [cited 2020 Nov 2];8(1):A08. Available from: http://www.cdc.gov/pcd/issues/2011/ jan/09_0214.htm
Giacomelli SC, Londero AM, Benedetti FJ, Saccol ALF. Comércio informal e formal de alimentos no âmbito escolar de um município da região central do Rio Grande do Sul. Braz J Food Technol. 2017;20:e2016136. https://doi. org/10.1590/1981-6723.13616
Food and Agriculture Organization of the United Nations. Healthy food environment and school food. Roma: Organization; 2020 [cited 2020 Aug 5]. Available from: http://www.fao.org/school-food/areas-work/food-environment/en/
Koletzko B, Fishbein M, Lee WS, Moreno L, Mouane N, Mouzaki M, et al. Prevention of childhood obesity: a position paper of the Global Federation of International Societies of Paediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN). J Pediatr Gastroenterol Nutr. 2020;70(5):702-10. https://doi.org/10.1097/MPG.0000000000002708
Bleich SN, Vercammen KA, Zatz LY, Frelier JM, Ebbeling CB, Peeters A. Interventions to prevent global childhood overweight and obesity: a systematic review. Lancet Diabetes Endocrinol. 2018;6(4):332-46. https://doi.org/10.1016/ S2213-8587(17)30358-3
Wolfenden L, Nathan N, Sutherland R, Yoong SL, Hodder R, Wyse RJ, et al. Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease. Cochrane Database Syst Rev. 2017;(11):CD011677. https://doi.org//10.1002/14651858.CD011677.pub2
Coutinho ESF, Huf G, Bloch KV. Ensaios clínicos pragmáticos: uma opção na construção de evidências em saúde. Cad Saude Publica. 2003;16:1189-93. https://doi.org/10.1590/S0102-311X2003000400039
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