**4. Discussion**

The results of our study highlight a critical situation in our sample of eight-year-old students with regard to the percentages of overweight (26.1%) and obese (15.2%), which were greater than those detected at the national and regional level [3]. As a matter of fact, according to Italian surveillance, the national and regional levels of pathological obesity are 9.4% and 15.1%, respectively. The overweight percentages do not offer better data: 20.4% and 21.6% at national and regional level, respectively [3]. With regard to sex, although the differences among nutritional status are non-significant, in our study males showed a lower percentage of overweight vs females at the local level as well as at regional level, and males showed a higher percentage of obesity at the local level as well as at national level [3].

It has been confirmed that data concerning the population of children and adolescents with respect to obesity and overweight are alarming and represent one of the most serious public health problems of our time [27]. This situation is correlated with bad habits, such as the consumption of processed foods rich in simple sugars and fats, and with high calorie diets associated with a sedentary lifestyle and with the growth of mechanized transport, urbanization, and information technology [5,7,28]. With regard to incorrect habits, our sample, compared with national population, showed a high level of skipping breakfast (10.8% vs. 8.7%), low intake of fruits and vegetables (40.2% vs. 24.3%), and unhealthy snacking (76.3% vs. 55.2%) [3]. The latter habits have been associated not only with bad nutritional status but also with low cognitive performance [9]. With regard to physical activities, 55% of the sample went to school by walking or cycling (compared with 26.6% at the national level), and 40.1% in the afternoon watch TV or play videogames/tablet/cellphones (compared with 44.5% at the national level). Although the local situations seem better than those at national level, unhealthy habits were still frequent in our sample and need attention.

In our sample, healthy lifestyles and correct food habits were not always correlated, and also, while the consumption of fruit for breakfast was considerable, this habit was not related to playing sports or other activities outdoors. This is a very important aspect since a low level of physical activity in young students leads to a reduction in physical activity/sport practice experienced adults, highlighting the necessity of promoting sports in this school-age period of life [8]. Therefore, the implementation of targeted interventions of education and health promotion in primary schools can undoubtedly favor the spread of healthy habits, which represents, especially in children, a useful investment in the prevention of the development of NCDs.

With regard to the correlation matrix in Figure 3, it confirms that unhealthy habits are more common among students who are obese or overweight. However, it is particularly interesting to underline that eating at school was more common among students with normal weight and, on the contrary, that obese and overweight subclasses were associated with students who did not eat at school. Although this evidence needs to be studied in depth, it highlights the potential role that the school environments may play in health promotion to prevent nutritional disorders [9]. Consuming a nutritionally correct meal, one that is adequate to the needs of children and adolescents in the school context, may represent a qualitative and quantitative guarantee with respect to the energy needs of this target population: often the school canteen is the only time when the meal consumed meets the macro- and micronutrient needs of children. More studies are needed in order to further analyze and to set the canteen menus to the energy expenditure of children.

At the same time, in order to fulfill its health promotion task, the school canteen has to completely respect the official rules; therefore, OC during the management of food service at school are needed. An adequate and more effective OC planning could contribute to achieving better results in terms of the capabilities of the inspections performed and preventive interventions adopted, especially in school environments.

Previous data report that 58.9% of the schools have their own internal school canteen, and in 52% of cases, the menu drafting is carried out by LHU dieticians; in the remaining 48%, the menu is edited by external professionals [16]. In our experience, in only 36.4% of the cases are meals prepared within the school, and this aspect has pros and cons: the presence of an internal canteen favors meals that are produced on site and immediately served, which guarantees the organoleptic qualities, consistency, and minimal alteration of foods [15]. On the other hand, the external cooking centers, managed by large companies, guarantee standardized procedural aspects, but it is necessary to consider that the transport phase in food delivery bags has a few critical points (e.g., with respect to hot or cold chains) [15]. From our OC on food hygiene and nutritional safety, although there is substantial compliance with the regulatory requirements, some prescriptions aimed at conforming structural aspects were issued and, in some cases, it was necessary to investigate specific nutritional aspects at later stages. No difference was reported between schools having an internal or external food service. The constant and targeted control system for this type of activity is able to detect substantial and formal deficiencies and promote timely corrective actions, even potentially related to reducing the risks of foodborne diseases. Moreover, in our study, all the registered non-conformities were solved during the same scholastic year. This demonstrates that it is possible to obtain full compliance to the rules of law only by constant monitoring. The current local organization of OC can allow a single access made by a team of different healthcare professionals (medical doctor, dietician, environmental health officers, food technologist, etc.), each with a different training background, useful for creating favorable synergies with FBOs and for improving verification in the field, assessing both nutritional and hygienic–sanitary aspects jointly. To be completely efficient, these OC should also foresee laboratory test of environmental matrices and food, such as is done in other human environments [29].

To our knowledge, this is the first study reporting integrated data on children's nutritional habits and OC in school canteens, which jointly investigated many aspects by different healthcare professional in a single inspection, an approach that is favored by regional reference laws, which are innovative in this regard [15,23].

The authors are aware of some limitations of the study. First, lifestyles were not investigated in depth, in order to avoid an excessive length of the questionnaire, the compilation of which could have favored rejection. This could have hidden important information, such as the children's energy expenditure, as well as other sociodemographic variables that were not collected. Furthermore, this study was targeted to a sample of students attending schools that are not representative of the whole population of students in Italy. Therefore, our study can be considered as preliminary research. Due to the limitation in representativeness, further studies are needed to deepen the investigation in this subpopulation.

Furthermore, the study was conducted before the COVID-19 pandemic. Different studies have demonstrated that sedentary behaviors increased and that all physical activities decreased significantly during the lockdown [8]. Therefore, incorrect habits highlighted

during the present study can be further worsened by the preventive measures adopted in response to the pandemic emergency. Since promoting physical activity during nonpandemic periods may also have positive effects in case of a lockdown [8], greater emphasis will have to be given to school interventions to promote healthy lifestyles, including those associated with OC conducted in school contexts. Finally, it should be noted that, in contrast with infectious diseases—where surveillance systems are already implemented for both health risk assessment and early detection also in critical situations [30,31]—continuous surveillance systems for risk factors of NCDs, such as overweight and physical inactivity, are very difficult to implement and maintain.

## **5. Conclusions**

This study reports some critical issues regarding nutritional status and habits in eight-year-old students and some features of school canteen services. It is noteworthy to underline how 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 contribution that the school canteens may provide for health promotion and prevention of nutritional disorders. On the other side, in order to fulfill its health promotion task, school canteens have to comply with official regulations and guidelines at every step of food chain; therefore, OC on school food management services are needed.

Data obtained from the present study may be useful in developing and implementing effective policies able to integrate nutrition education and OC for a healthier school environment.

**Author Contributions:** Conceptualization, V.M., G.D.S., and C.N. (Christian Napoli 7); methodology, G.D.S., P.M., S.F. and P.P.; software, validation, and formal analysis, V.M., S.R., C.N. (Christian Napoli 4) and C.N. (Christian Napoli 7); investigation, S.F., G.D.S. and P.M.; data curation, V.M., G.D.S., S.R., C.N. (Christian Napoli 4) and C.N. (Christian Napoli 7); writing—original draft preparation, V.M. and C.N. (Christian Napoli 7); writing—review and editing, G.B.O., M.T.M., P.P., V.M., G.D.S., C.N. (Christian Napoli 4) and C.N. (Christian Napoli 7); supervision, G.D.S., P.M., P.P. and M.T.M.; project administration, G.D.S., P.M. and S.F. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy and ethical reasons.

**Conflicts of Interest:** The authors declare no conflict of interest.
