Availability and consumption of ultra-processed foods in schools in the municipality of São Paulo, Brazil: results of the SP-Proso

Leite, Maria Alvim; Azeredo, Catarina Machado; Peres, Maria Fernanda Tourinho; Escuder, Maria Mercedes Loureiro; Levy, Renata Bertazzi

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ARTICLE • Cad. Saúde Pública 37 (suppl 1) • 2021 • https://doi.org/10.1590/0102-311X00162920 copy

Availability and consumption of ultra-processed foods in schools in the municipality of São Paulo, Brazil: results of the SP-Proso

Authorship SCIMAGO INSTITUTIONS RANKINGS

Ultra-processed foods are markers of unhealthy eating patterns, and their consumption is high among adolescents. Characteristics of the school eating environment associate with student eating practices. This study aims to investigate the association between the presence of school canteens and the availability of ultra-processed foods in school canteens with the consumption of these foods, inside the school, among adolescents of the 9th grade (14 years) of the public and private schools of the city of São Paulo, Brazil. We conducted a cross-sectional study with SP-Proso data, in a sample of 2,680 adolescents. We elaborated multilevel linear regression models to evaluate associations between the exposures: presence of school canteens and availability of ultra-processed foods with outcomes of consumption frequency of ultra-processed foods in the school. We found an association between the presence of school canteens and the higher frequency of consumption of sausages (0.46; 95%CI: 0.24; 0.68), package snacks (0.50; 95%CI: 0.19; 0.80), goodies (0.82; 95%CI: 0.55; 1.09), and sugary drinks (0.34; 95%CI: 0.06; 0.62), as well as a score of consumption frequency of ultra-processed foods (2.37; 95%CI: 1.25; 3.48). The availability of package snacks, goodies, and sugary drinks in school canteens increased the frequency of consumption of these foods. We observed a dose-response effect between the diversity of ultra-processed foods in canteens and the frequency of consumption of these foods. A school food environment with greater availability of ultra-processed products is associated with their higher consumption in school, indicating the need to regulate the sale of food within these institutions.

Keywords:
School Feeding; Adolescent; Multilevel Analysis

	Total		Students from schools without canteens (20.4%)		Students from schools with canteen (79.6%)
	%	95%CI	%	95%CI	%	95%CI
Individual characteristic
Age (years) [mean]	14.8	14.8; 14.9	15.0	15.0; 15.1	14.8	14.7; 14.8
Sex
Female	47.4	45.7; 49.1	47.7	43.4; 52.0	47.3	45.5; 49.1
Male	52.6	50.9; 54.3	52.3	48.0; 56.6	52.7	50.8; 54.5
Maternal education
Complete middle school	24.8	22.7; 27.0	34.2	31.2; 37.4	22.4	19.8; 25.2
Incomplete or complete high school	40.2	37.5; 42.9	44.1	40.0; 48.2	39.2	35.9; 42.5
Incomplete or complete higher education	35.0	32.1; 38.1	21.7	17.9; 26.0	38.4	34.5; 42.5
Score of goods and services
Low	33.5	30.6; 36.6	43.9	38.2; 49.7	31.0	27.6; 34.6
Medium	40.0	37.0; 43.0	39.5	34.2; 45.1	40.1	36.6; 43.7
High	26.5	23.4; 29.9	16.6	13.8; 19.8	28.9	25.1; 33.1
Skin color
White	44.2	41.7; 46.8	34.0	31.1; 37.0	46.8	43.6; 50.2
Black	49.1	46.3; 51.9	59.6	55.0; 64.1	46.3	42.7; 49.9
Others	6.7	5.5; 8.1	6.3	4.0; 10.0	6.8	5.5; 8.4
Mean frequency of consumption of ultra-processed foods at school (days) [minimum = 0; maximum = 5]
Sausage-like	1.3	1.2; 1.4	1.0	0.9; 1.2	1.3	1.2; 1.4
Cookies and crackers	2.2	2.1; 2.3	2.1	1.9; 2.3	2.2	2.1; 2.0
Package snacks	1.5	1.4; 1.6	1.4	1,2; 1,5	1.6	1.4; 1.7
Goodies	2.2	2.1; 2.3	1.8	1.7; 2.0	2.3	2.2; 2.5
Sugar-sweetened beverages	1.9	1.8; 2.0	1.6	1.4; 1.8	1.9	1.8; 2.1
Score of ultra-processed consumption at school [minimum = 0; maximum = 25]	9.1	8.6; 9.5	7.8	7.1; 8.6	9.4	8.9; 9.8
School features
Administrative dependency of the school
Private	27.1	27.1; 27.1	0.0	-	100.0	-
Public	72.9	72.9; 72.9	36.1	33.0; 39.3	63.9	60.7; 67.0
School size (number of students)
200-500	9.9	5.1; 18.5	8.8	2.1; 29.8	10.3	4.8; 20.8
500-1,000	47.7	36.7; 57.7	59.7	41.7; 75.4	42.6	30.4; 55.9
More than 1,000	43.0	32.8; 53.9	31.5	17.6; 49.6	47.0	34.4; 60.1
Class shift
Full time	1.5	0.2; 9.9	0	-	1.9	0.3; 12.9
Morning	70.2	59.6; 78.9	70,7	52.8; 83.9	70.0	57.0; 80.4
Afternoon	28.4	19.8; 38.9	29.3	16.1; 47.2	28.1	18.0; 41.0
Mean score of ultra-processed foods sold in canteens [minimum = 0; maximum = 5] *
First category (mean score = 2.30)	-	-	-	-	23.8	15.9; 34.2
Second category (mean score = 4.00)	-	-	-	-	28.6	18.4; 41.5
Third category (mean score = 5.00)	-	-	-	-	47.6	35.1; 60.4
Absence of structured cafeteria	14.7	8.5; 24.3	13.7	4.4; 35.1	15.0	7.9; 26.5
Presence of an alternative food selling point	3.7	1.5; 8.8	1.4	0.2; 9.5	4.5	1.7; 11.3
Presence of a street vendor in front of the school at the end of classes	22.3	15.3; 31.4	23.4	12.5; 39.6	21.9	13.6; 33.3
Presence of advertising of ultra-processed foods **	5.5	2.4; 11.9	2.7	0.6; 10.6	6.4	2.6; 15.1

Frequency of consumption of ultra-processed foods at school	Crude models			Fitted models 1 *			Fitted models 2 **
Frequency of consumption of ultra-processed foods at school	Coefficient	95%CI	p-value	Coefficient	95%CI	p-value	Coefficient	95%CI	p-value
Sausage-like	0.28	0.11; 0.46	0.002	0.52	0.30; 0.74	< 0.001	0.46	0.24; 0.68	< 0.001
Cookies and crackers	0.15	-0.05; 0.35	0.149	0.31	0.07; 0.55	0.012	0.21	-0.06; 0.48	0.135
Package snacks	0.23	0.01; 0.45	0.037	0.59	0.33; 0.86	< 0.001	0.50	0.19; 0.80	0.001
Goodies	0.49	0.30; 0.69	< 0.001	0.82	0.58; 1.06	< 0.001	0.82	0.55; 1.09)	< 0.001
Sugar-sweetened beverages	0.36	0.16; 0.57	0.001	0.39	0.14; 0.64	0.003	0.34	0.06; 0.62	0.017

Frequency of consumption of ultra-processed foods at school	Crude models			Fitted models 1 *			Fitted models 2 **
Frequency of consumption of ultra-processed foods at school	Coefficient	95%CI	p-value	Coefficient	95%CI	p-value	Coefficient	95%CI	p-value
Cookies and crackers	0.06	-0.14; 0.26	0.556	0.09	-0.12; 0.31	0.386	0.08	-0.13; 0.30	0.441
Package snacks	0.35	0.14; 0.56	0.001	0.45	0.23; 0.67	< 0.001	0.38	0.13; 0.63	0.002
Goodies	0.51	0.32; 0.70	< 0.001	0.69	0.47; 0.91	< 0.001	0.69	0.44; 0.94	< 0.001
Sugar-sweetened beverages	0.37	0.16; 0.57	< 0.001	0.38	0.15; 0.61	0.001	0.35	0.10; 0.59	0.005

	Crude models			Fitted models 1 *			Fitted models 2 **
	Coefficient	95%CI	p-value	Coefficient	95%CI	p-value	Coefficient	95%CI	p-value
Exhibition: presence of canteens	1.50	0.69; 2.32	< 0.001	2.61	1.6; 3.61	< 0.001	2.37	1.25; 3.48	< 0.001
Exposure: score of ultra-processed products sold in canteens [minimum = 0; maximum = 5] ***
First category (mean score = 2.30)	0.21	-0.90; 1.32	< 0.001	1.16	-0.35; 2.68	< 0.001	1.11	-0.39; 2.61	0.011 ^#
Second category (mean score = 4.00)	1.68	0.65; 2.72	< 0.001	2.37	1.24; 3.50	< 0.001	2.18	0.94; 3.41	0.011 ^#
Third category (mean score = 5.00)	2.23	1.30; 3.15	< 0.001	2.90	1.79; 4.02	< 0.001	2.72	1.47; 3.98	0.011 ^#

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[1] Correspondence
M. A. Leite Av. Dr. Arnaldo 455, São Paulo, SP 01246903, Brasil. maria.alvim.leite@gmail.com