*Article* **An Integrated Control Plan in Primary Schools: Results of a Field Investigation on Nutritional and Hygienic Features in the Apulia Region (Southern Italy)**

**Vincenzo Marcotrigiano 1,\*, Giacomo Domenico Stingi 1, Simona Fregnan 2, Pantaleo Magarelli 1, Pietro Pasquale 3, Samuele Russo 4, Giovanni Battista Orsi 5, Maria Teresa Montagna 6, Christian Napoli <sup>4</sup> and Christian Napoli <sup>7</sup>**


**Abstract:** Data concerning overweight and obesity in children and adolescent populations are alarming and represent one of the most serious public health problems of our time. Moreover, it is demonstrated that the school environment may play an important role in health promotion with regard to nutritional aspects. This article reports the results of a study conducted in the Apulia region (Southern Italy), aimed at providing an integrated surveillance of the behaviors related to nutrition habits in students and the hygienic and nutritional conditions of the school's canteens attended by enrolled students. To this purpose, a sample of 501 students attending primary school (third class—children approximately eight years old) replied to a validated questionnaire, and official controls (OC), of both food and nutritional safety, were performed in 22 primary schools. A team of healthcare professionals carried out the study, and the implementation of all the prescribed improvement actions were subsequently verified through follow-up OC. The results of our study show a critical situation in the student sample, with 41.3% of children having a weight excess (overweight or obesity). With regard to the children's behaviors, only 59.8% of children ate at least one fruit or had a fruit juice for breakfast, and 10.8% did not have breakfast at all. Overall, 40.1% of the total children played outdoors the afternoon before the survey and 45% reported going to school on foot or by bicycle. During the afternoon, 83.5% of the sample watched television or used video games/tablets/mobile phones, while 42.3% played sports. The schools had an internal canteen with on-site preparation of meals in 36.4%, the remaining 63.6% received meals from external food establishments. With regard to OC, for the hygienic–sanitary section, eleven prescriptions were issued, in the great part related to the structure and organization of the canteen. For the nutritional section, nine corrective actions were prescribed, mainly related to official documents and management. The follow-up OC showed that all prescriptions were subsequently addressed. Eating at school was less frequent among obese and overweight students compared with those with normal weight. Although this evidence needs to be further confirmed, it highlights the potential role that the school canteens may play in health promotion and prevention of nutritional disorders. On the other hand, in order to fulfill its health promotion task, the school canteens have to comply with official regulations and guidelines; therefore, OC during the management of the food service at school are needed.

**Citation:** Marcotrigiano, V.; Stingi, G.D.; Fregnan, S.; Magarelli, P.; Pasquale, P.; Russo, S.; Orsi, G.B.; Montagna, M.T.; Napoli, C.; Napoli, C. An Integrated Control Plan in Primary Schools: Results of a Field Investigation on Nutritional and Hygienic Features in the Apulia Region (Southern Italy). *Nutrients* **2021**, *13*, 3006. https://doi.org/ 10.3390/nu13093006

Academic Editors: Massimo Lucarini and Alessandra Durazzo

Received: 29 July 2021 Accepted: 25 August 2021 Published: 28 August 2021

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**Keywords:** nutritional knowledge; eight-year-old students; health promotion; official control; school canteen

#### **1. Introduction**

The spread of non-communicable diseases (NCDs), such as obesity, has become a paramount concern in the world health panorama. In order to limit the spread of such diseases, the World Health Organization (WHO) has identified different strategic areas of intervention for health promotion [1]; however, such actions first require a precise assessment of the state of health in the target population. In Italy, where obesity and overweight have been identified among the priority areas for intervention, a national surveillance project for nutritional status assessment and related factors in children at the third year of primary school started in 2008 [2]. The last survey was conducted in 2019 and showed that 20.4% of eight-year-old children were overweight, while 9.4% were affected by pathological obesity [3]. In particular, males were more affected, especially in the southern regions of Italy, as well as in families with a disadvantaged economic status [3].

The selected age group (eight-year-old) is considered a main target for prevention; in fact, the choices, attitudes, and behaviors adopted at this age have life-long repercussions and can be further amplified by other factors, especially in the adolescent period [4]. An international study conducted in 2018, investigated the Italian population aged 11, 13, and 15 years. This latter study highlighted that 16.6% of the subjects of this group were overweight, while 3.2% were obese. Overweight and obesity seem to affect males more often than females, and there is a confirmed higher prevalence in the southern regions than in the central–northern ones [4]. These data are also in line with the nutritional status among university students: a study in southern Italy reported a 17.8% and 3.4% prevalence of overweight and obese students, respectively [5].

Comparison with international data shows that weight excess is more common in Italian youth (in all age groups) with respect to the European average [6]. In addition, the COVID-19 pandemic also worsened this situation, aggravating lifestyle habits, limiting physical activities, and creating psychological distress [7,8].

It is also demonstrated that nutritional status in school-aged children is related to unhealthy behaviors (such as skipping breakfast, low intake of fruits and vegetables, and unhealthy snacking) and insufficient physical activity, which may be reflected in cognitive performance too [9,10]. In Italy, with regard to these aspects, the last national survey on nutritional aspects showed that 44.3% of children skip or have an inadequate breakfast, 24.3% do not eat fruit or vegetables daily, unhealthy snacks are consumed by 48.3%, and 20.3% do not practice any physical activity [3]. At the same time, the increasing prevalence of childhood overweight and obesity is often related to school environment features [9].

Children spend six or more hours per day at school for more than six months per year; therefore, an education intervention focused on improving nutrition knowledge, attitudes, and practices among primary school children must also involve the food quality available at school canteens. Health promotion interventions for school canteens, aimed at offering healthier food, seem promising and effective in improving the school food environment [11].

In light of these data, the Apulia region has identified schools to be one of the most important settings for health promotion, also from a nutritional point of view. Therefore, starting from the forecasts of the Regional Prevention Plan (PRP) 2010–2013 with the "School in Health" program, a "Regional Strategic Plan for Health Promotion in Schools: Catalogue" is also periodically issued [12,13]. Subsequently, the 2014–2018 PRP further focused its attention on the need to also provide guidelines on nutritional safety [14]. Therefore, the Regional Decree no. 1435 of 2 August 2018 has drawn up the "Guidelines for School and Corporate Catering" to ensure the adoption of correct eating habits for health promotion and disease prevention, fighting against an incorrect diet [15].

Starting from the new regional guidelines, this article shows the results of an integrated project aiming to (i) evaluate anthropometric data and behaviors in terms of nutrition habits in a sample of students attending primary school (third class—children approximately eight years old); (ii) carry out, in the same schools, the official controls (OC) in terms of both hygiene conditions and nutritional normative aspects foreseen by the DGR no. 1435 of 2 August 2018; and (iii) verify, through follow-up OC, the implementation of all the prescribed improvement actions.
