Healthy eating at school: consensus among experts Alimentação saudável no ambiente escolar: consenso entre especialistas

1 Universidade Federal de São Paulo. Instituto Saúde e Sociedade. Programa de Pós-Graduação Alimentos, Nutrição e Saúde. Campus Baixada Santista, R. Silva Jardim, 136, 11015-020, Santos, SP, Brasil. Correspondência para/Correspondence to: RGM CAMARGO. E-mail: <raguimanutri@gmail.com>. 2 Universidade Federal de São Paulo. Instituto Saúde e Sociedade. Programa de Pós-Graduação Alimentos, Nutrição e Saúde. Santos, SP, Brasil. 3 Universidade Federal de São Paulo. Instituto Saúde e Sociedade. Departamento de Saúde, Clínica e Instituições. Santos, SP, Brasil. 4 Universidade Federal de São Paulo. Instituto Saúde e Sociedade. Departamento de Políticas Públicas e Saúde Coletiva. Santos, SP, Brasil. ORIGINAL | ORIGINAL


I N T R O D U C T I O N
Currently, the Brazilian population has a high proportion of overweight and obese individuals; this problem has been exacerbated by the eating habits of children. Population studies show a low consumption of healthy foods such as beans, fruits, vegetables, and dairy products and a high consumption of processed and ultraprocessed foods at this stage of life 1-2 .
The Programa Nacional de Alimentação Escolar (PNAE -National School Meal Program) is the oldest and largest food and nutrition program in Brazil. It serves all students in basic education and contributes to learning, growth, and school performance in addition to stimulating the biopsychosocial development of children 3 . The quality of school meals in Brazil has progressively improved following deployment of initiatives such as the transition of the food supply as a requirement to purchase food produced by family farms 4 , which have impacted on school menus. In this context, the PNAE plays an important role in the promotion of healthy eating 5 through food and nutrition educational activities and meal provision. Menu planning should be in accordance with established legal parameters that provide the mandatory supply of fruit and vegetables, ban the purchase of sugary drinks with low nutritional value, and restrict the purchase of ultra-processed foods 3 .
In order to determine their effectiveness, indicators have been developed to monitor and evaluate programs, given the scarcity of studies assessing the impact of nutrition programs in Brazil. These indicators provide subsidies so that decision makers can plan investments, redesign programs, and strengthen mechanisms for policies associated with social control 6 4 . However, neither tool has been validated. The IQCAE scores and components were designed to promote menus that include important foods to supply nutrients and bioactive compounds over those menus containing products with low nutritional density or that pose health risks when consumed frequently [8][9][10] .
Several methodological approaches are used to assess the validity of an instrument in order to evaluate precision as well as ability to measure its intended target. Content validation evaluates the alignment of the items that make up the instrument to a theoretical framework; these items are organized on the basis of consultation with experts on the subject in question 11 .
Given the lack of validated instruments to assess the quality of food served to children in basic education in our country, this study aimed to consult experts in the field of school feeding in order to identify the attributes associated with promoting healthy food in order to support content validation of the IQCAE based on a consensus on 'Healthy eating' and 'Quality index for school feeding menus'.

M E T H O D S
In order to create the panel of experts consulted in this study, nutritionists who had published articles from April 2010 to November 2015 were selected by searching the Web of Science database using the keywords 'school feeding', 'school nutrition program', and 'school food program', in addition to 'Brazil' as the study location. The education of authors in nutrition was confirmed by consulting the Lattes Platform a repository of curriculums of the National Council for Scientific and Technological Development.
Nutritionists who were authors of official documents of the Ministry of Health and Education regarding school meals and textbooks developed by the Collaborating Centers in School Food and Nutrition were also included. To identify the electronic addresses of these experts, we used the Google search engine and the Lattes Platform.
The instrument used in this study was constructed based on IQCAE 4 components (Chart 1, then organized into two analytical dimensions composed of 16 assertions (Chart 2) and an open question ("Please point out themes and/or issues that were not addressed herein and that you feel are important to building a consensus on 'Healthy eating' and 'Quality' index for school meal menus" 12 ). Equivalent assertions were proposed in order to confirm the consistency of their responses (probe).  14,15 in two rounds.
The experts were asked to read an introductory text in order to understand the method used and the concepts and themes that were discussed during the study. They were also provided an Informed Consent Form.
Four analyses were combined to define consensus in order to ensure the results obtained for each of the assertions: 1. Scoring of each assertion: the average value was used for verification of data behavior and its dispersion 12,13,16 , based on the following definitions: From 1.00 to 1.99 points: Poor perception of the evaluated object, which implied the necessity for changes or substitutions. From 2.00 to 2.99 points: The perception indicates the need for adjustments in the assessed object, but an overall positive perception of its implementation. Regular consumption of fruits, vegetables, cereals, meat, milk, and dairy products supports a healthy diet. a

3
Based on their level of processing, processed cookies belong in the formulated foods group. a 3 A healthy diet does not contain foods with a low degree of processing. b

4
Characteristics of margarine production justify its classification as a formulated/ultraprocessed food. a

5
A daily supply of formulated/ultra-processed foods is not adequate. a The criteria for building a quality indicator for school lunch menus should be stricter for foods high in fat or sugar, given the risks associated with their consumption. a 16 A quality indicator for school meal menus, in addition to being a support tool for dietitians, can also be used as a tool for nutritional care actions and promotion of food security and nutrition. a  The instrument was pre-tested by two researchers of school nutrition to adjust phraseology and improve each of the claims. This study was approved by the Ethics Committee of Universidade Federal de São Paulo (Federal University of São Paulo, CAAE nº 42685615.1.0000.5505). The experts received study clarification by email along with a link to access the survey instrument through Question Pro software.

Experts profile
Of the 94 experts invited to participate in the study, 27 responded to the first round; of these, 18 (66.7%) responded to the second round, corresponding to a satisfactory expert response rate (28.0%) that was comparable to that obtained in other studies of the same nature. It should also be noted that the questionnaires were sent to nutritionists throughout the country 12,16,17 .
Of the total participants, 92.6% were affiliated with public institutions; 37.0% belong to the South Region, 22.2% to the Southeast and 29.6% to the Midwest. The Northeast (7.4%) and North (3.7%) Regions also contributed with answers. All respondents reported having experience in School Feeding area: 29.6% had between one and five years of experience; 55.6% had between six and ten, and 14.8% had over 15 years.
Over 70.0% of respondents rated their training in School Feeding area during their education as inadequate (66.7%) or very poor (7.4%). Only 25.9% considered their training to be adequate, which shows the perception of an insufficient approach to the nutrition in undergraduation courses of Brazil 17,18 .
Regarding experience in the subject, 37.0% of researchers believed themselves to be highly qualified; 55.6% to have proper qualifications and 7.4% were poorly qualified. The highest degree among the researchers was postdoctorate (3.7%); 48.1% achieved a doctorate; 40.7% had a masters degree, and 7.4% had undergraduate degrees. A study that examined the nutritionist profession in Brazil reported that, over 70 years, only 2.4% and 9.4% of the professionals were in a university program or had doctorate or master's degrees, respectively. Our findings show that the respondents had experience in the field, thus supporting our selection criteria for the identification of experts. However, there is a need to qualify the training for school nutrition area during undergraduation, considering the lack of educational experience reported by the majority of the experts; this deficit in nutrition courses has been previously identified 18 .

First round
Two rounds of feedback and review of responses were performed to consolidate the consensus, as described in similar studies 16 . The dimensions analyzed reached consensus with an average of 3.3 points (±0.6) and 3.42 points (±0.4) for 'foods that are part of a healthy menu for school feeding' and 'composition of an indicator of nutritional quality for school feeding menus', respectively. Table 1 shows the analysis used to establish the consensus for Dimensions 1 and 2. Assertion numbers 10, 11, and 15 did not reach a consensus in the first round and were presented to the experts again in the second round, accompanied by a theoretical foundation so that it was possible to establish a consensus.

Second round
The experts received the results of the first round, including the results for each assertion, as well as the theoretical basis for the suggestions that were issued during the first round. These results were grouped into thematic blocks already included in the indicator. Other suggestions from the experts and not yet included in the indicator were used as research material for future study for improvement of the IQCAE. At the end of the second round, the experts received the overall result of the consensus. The two dimensions analyzed reached a consensus with an average of 3.4 points (±0.3) for 'foods that are part of a healthy menu for school feeding' and 3.5 points (±0.3) for 'composition of an indicator of nutritional quality for school feeding menus'.
Consensus was not reached in the first round for assertion 10 (Foods high in sugarchocolates, candies preparations or stuffed cookies -can be part of a healthy diet, if consumption is not frequent and in small quantities), based on the criteria of average points (2.7) and an interquartile range greater than 1 (1.5). Based on the following theoretical basis: The consumption of foods rich in sugar harms a balanced diet due to a high glycemic index, low nutrient content, and a lower consumption of foods with high nutritional density 19  According to Giannarou & Zervas 16 , percentages above 51.0% are sufficient to sustain the consensus for the assertion. Like the IQCAE, the AQPC-School is cautious on the subject of including sugar among 'controlled' components, which should, wherever possible, be replaced by natural foods 7 .
A consensus was not reached in the first round for assertion 11 (Foods rich in fat such as cream, butter, pâté and sauces; if consumption is not frequent or occurs in small quantities, it can be part of the diet) due to not meeting the criterion of average points (2.7). However, after introducing the theoretical basis: This result shows how the approach for the effects of the lipid fraction of food on health remains sensitive among experts, although the most recent evidence suggest the need to revise fat intake limits and to consider the adverse risks of the simple replacement of this macronutrient by carbohydrates 20 .
Finally, a consensus was not reached for Assertion 15 (The offer of a sweet replacing a meal is inadequate) in the first round based on the interquartile criterion (1.5); however, after the theoretical basis: Among the objectives of the school nutrition is the adequate and sufficient supply of energy and nutrients for children during their stay in the classroom, in addition to promote the formation of healthy eating habits 21 ; the replacement of a meal by a sweet compromises the quality of food; this assertion has been revised to provide greater clarity about the construct that it is based upon. the four criteria were met and a consensus was reached. The 'mealtimes' and 'processed/ formulated foods' themes were considered in assertions 12, 14 and 2, 3, 4, and 5, respectively, and the consistency of response was fulfilled (probe).
In response to the open question, 18 themes for discussion were generated, among them eight that were already included in the IQCAE and were therefore sent to the participants with a theoretical basis (Chart 3) in order to enhance their understanding of the themes of the indicator, which reinforced the subsequent study of the content validation. The others were grouped into thematic blocks and can support future studies to improve the indicator; they include organic foods (n=6 participants who made the suggestion); food/regional preparations, crop and family farms food (n=15); whole foods (n=2); eating together (n=1); special dietary requirements (n=1); preparation techniques (n=2); meeting nutritional recommendations (n=1); pesticides and genetically modified seeds (n=2); acceptability of the preparation (n=2); menu variety (n=1).
Our findings confirm that the IQCAE components correspond to healthy eating markers under school nutrition were recognized by the consensus of the experts recruited for this study, including natural foods such as fruits and vegetables, meat and eggs, dairy products, beans, and grains. At the same time, the following were also confirmed as risk markers for student health: processed/formulated foods (sausages and processed meats), foods rich in fat, and foods rich in sugar. Kranz et al 36

Definition of dessert, since it is not always a sweet (excess sugar), and may also be a fruit Foods high in sodium Population profile, different realities
The compatibility of time in which meals are offered with the type of meal is based on culture and eating habits; hypothalamic activity guides the circadian rhythm and sends signals via neuroendocrine system that regulates the appetite; changes in food supply routine can disrupt behaviors associated with food intake and lead to metabolic changes; it is up to nutritionists to determine at which times meals are served 3,22 . The indicator under study values the offer of the type of meal associated with time: snacks until 10:30AM and lunch between 10:00AM and 2:00PM.
Although the intake of saturated fat-rich foods has been associated with the development of cardiovascular diseases in the past, there is no conclusive evidence of this risk for scholars; a moderate consumption of fat balances the distribution of other nutrients, increases satiety, provides essential fatty acids, and improves the palatability of the diet; replacing food sources of fat for carbohydrates, common in diets with lipid restriction, does not provide metabolic benefits that justify this guideline 23 . In the indicator under study, the groups of meat and dairy products groups, important sources of fat in school meals, receive positive scores.
The supply of iron is guaranteed by consumption of meat, eggs, and beans, although there are differences in bioavailability of the mineral. The functions of iron include transport of oxygen and carbon dioxide for gas exchange between lungs and tissues, which is essential for the development of vital organism activities 8 . Anemia remains a public health problem in Brazil; the prevalence of iron deficiency anemia is above 50% among children in nursery and schools 9 . Preformed vitamin A (retinol) is found in foods of animal origin such as butter and eggs; among the carotenoids with pro-vitamin A activity is beta-carotene, which also has antioxidant activity and can be found in yellow and orange fruits and vegetables as well as dark green leafy vegetables; both play an important role in visual function, gene expression, cellular differentiation, and immunity 24 . The supply of these micronutrients is included in the IQCAE in the groups of meat and eggs, beans, fruits, and vegetables, which received positive scores when offered in the school menu.
Fruits and vegetables make up the natural food group 25 provide essential micronutrients and bioactive compounds for maintaining health and reducing the risk of non-communicable chronic diseases, especially obesity. They possess anti-inflammatory and antioxidant properties, among others funcions 10,26 . More than half of the population in Brazil is overweight, and 15% of these are children 27 . Consumption of a nutritionally complete diet and healthy eating are considered prevention factors 10 . Dairy products are considered minimally processed foods 25 and are the main food sources of calcium, an essential mineral for maintaining bone structure 28 . Fruit juices are considered fruit only when there is no added sugar, or when described as 'natural juice of fruit'.The IQCAE values fruits and vegetables, which are included in the 'vegetables' group. Dairy products are included in the 'cheese, milk, and yogurt' group.
The term 'formulated' refers to industrially-produced compounds which allow for immediate consumption or instant preparation, which may employ brief heat; in most cases, they have low nutrient density and, eventually, high energy density. These components generally contain high amounts of sodium, fat, or sugar 29,30 . For many years, school nutrition was characterized by the use of formulated foods due to its centralized management, making barrier to include local commerce and family farming in the supply of healthy foods to students 5 .
The statement which refers to 'a sweet or dessert as a meal'; i.e., the use of these foods to replace a meal, whether it is a sweet dessert (excess sugar) or a single fruit.
Foods high in sodium belongs to processed and formulated group (ready spices, processed crackers, and soups, among others). The consumption of these foods must be limited, since the processing mechanisms contribute to the loss of the nutritional composition of the main ingredients, and excess of sodium is associated with the development of chronic diseases and metabolic syndrome 30,31 . Sodium intake among Brazilian adolescents between 10 and 18 years is higher than recommended 32 . The processed of sausages and formulated foods on the menu results in decreased IQCAE.
The IQCAE originally was designed to evaluate shcool menus from competing for the Efficient Manager of School Meals Award, a national prize intended to promote good management in the municipalities. Among the various categories evaluated for this prize is Nutritional Efficiency 33 , which required the design of an instrument for this purpose published in 2011 34 and adapted in 2012 4 . The components of the IQCAE allow for the organization of different menus; the construction of diet quality indices is supported in dietary guidelines and food guide recommendations, giving rise to levels targeted to specific objectives and populations 35 . Theoretical foundation n Note: n=Number of experts who suggested the theme. eicosapentaenoic acid, total grains and whole grains 36 ; however, a proposal for a quality indicator that dispenses the quantitative measurement of nutrients and enhances food is in line with recent guidelines on the subject, such as those used to develop the Food Guide for the Brazilian population 25 .
The components vegetables, fruit, 100% natural fruit juice, dairy and consumption of iron, also identified in other studies 36 , are already considered in the indicator in this study. When proposing the AQPC-School, Veiros & Martinelli 7 classified foods into two groups: 'foods that should be recommended' and 'foods that should be controlled'; based on this indicator, the recommended foods include fresh fruits; salads; non-starchy plants; cereals, bread, pasta and starchy vegetables; whole foods; meat and eggs; legumes; and milk and dairy products. The controlled foods include processed sweets and added sugar; sausages and processed meats; ready-to-eat processed foods; canned and preserved foods; dehydrated food concentrates or in those in powder form; breakfast cereals, cakes, and biscuits; flatulent foods and those difficult to digest; beverages with low nutritional value; preparations with repeated colors in the same meal; fried foods, fatty meats; and fatty sauces. With the exception of preparations with repeated colors and supply of flatulent food, it is clear that there is a similarity between the IQCAE assessed in the current study and AQPC-School.
The concept of healthy eating has undergone constant changes throughout the history of the science of nutrition, responding to political and social influences as well as the interests of various stakeholders in food standards, particularly in the food sector. Academic studies that explore the concept of healthy eating by offering a critical analysis of different viewpoints broaden our understanding of what 'eating well' means in contemporary times 37 . Although 'Healthy Eating' is a theme widely recognized by professionals, which has been recently discussed in the updated GAPB 25 , consolidation of this consensus required two rounds with accompanying explanations based on theoretical foundations. Therefore, this study sought to identify dimensions that contributed to validation of the content of the IQCAE, an instrument with the potential to support policy monitoring activities and food programs, including the Programa Nacional de Alimentação Escolar.
The limitations of this study result from the sampling of experts: nutritionists with publications in the field and authors of official documents did not necessarily work directly with school nutrition, even though they had academic experience in the area.

C O N C L U S I O N
A consensus on healthy diet has been established for two major food groups: 1) foods that should be consumed daily, including fresh foods such as fruits and vegetables, meat and eggs, dairy products, beans, and grains; and 2) foods that should be eaten at low frequency, such as processed and formulated foods (sausages and processed meats), as well as foods rich in fat and sugar. The time that meals should be offered, a component included in the IQCAE was also considered relevant by the experts consulted in this study, which sets this indicator apart from other available tools.
However, the experts were unable to reach a consensus regarding other aspects of school nutrition, including foods rich in sugar, sweets replacing meals, and foods rich in fat. The theoretical foundation, however, was enough to form an understanding regarding these issues.
These results may support the proposal for mechanisms to monitor the quality of school meals by indicating the components of protection or risk that will comprise an IQCAE content validation study. Reaching a consensus on both study dimensions also showed that, despite advances in the understanding of the effects of diet on health, there are sensitive issues among experts in the field, which points to future developments in this field regarding the quality of school nutrition. Rev