School-based food_-aid programs are an effective strategy for diminishing food insecurity in children and adolescents. The study purposes are to present the methodology for designing the meals of a novel school-based food_-aid program aiming to promote healthy nutrition and to verify food suppliers’ compliance to meal preparation specifications. All meals were designed based on international nutrition guidelines for school-based meals, as well as the Greek National Dietary Guidelines for children and adolescents. Strict specifications were applied regarding fatty acid content, including: a) exclusive use of extra virgin/virgin olive oil, b) <3% saturated fatty acid content in bread/bakery products and c) non-detectable levels of trans fatty acids. For salt/sodium and added sugars, low limits were set, which were further decreased within the Program’s development. Whole grain wheat flour (i.e. ≥ 60% of total added flour) was used in bread/bakery products so as to enhance dietary fiber and mineral content. To evaluate the nutrient content of meals, as well as food suppliers’ compliance to meal preparation specifications, random laboratory analyses were performed. During the Program implementation in the 2013-2016 school-years, 293 laboratory analyses were performed. High compliance rates for meal preparation specifications was observed, with exceptions mainly regarding fatty acid profile (8.4%; n=10/119) and sodium content (14.3%; n=3/21). Violations were communicated to food suppliers and financial penalties were applied; henceforth, similar incidences were eliminated. The strict requirements and structured verification process of the DIATROFI Program may serve as a practical prototype for delivering healthy school-based food_-aid, based on the principles of healthy eating.

•    Nutrition
•    Children
•    School meals
•    Food assistance
•    Laboratory analysis

Christina-Maria K, Matina K, Panagiotis G, Elena C, Anastasia P, et al. (2017) Development and Evaluation of the Nutrient Content of the DIATROFI School Food-Aid Program Meals. J Hum Nutr Food Sci 5(1): 1103.

School-based food-aid programs represent an increasingly adopted policy measure for addressing food insecurity in children and adolescents [1]. Moreover, due to their chronicity, such programs present a clear opportunity for establishing and enhancing healthy nutrition behaviors, particularly in disadvantaged population groups.

Developed countries experiencing protracted financial crisis, such as Greece, are facing increasing prevalence rates of poverty and food insecurity [2]. To this effect, a novel school-based food_-aid program, namely the DIATROFI Program (http://diatrofi.prolepsis.gr/en/ ), was developed with a dual purpose; to address the alarmingly rising childhood food insecurity rates in Greece by providing all students of participating schools with daily free quality meals and to promote healthy eating for the students and their families. The Program has been successfully implemented in low socioeconomic status areas throughout the country since 2012, having provided over 13 million meals to over 90.000 students in need. During Program implementation food insecurity has been decreased, while children’s dietary habits have shifted towards healthier patterns, including increases in white milk, fresh fruit, vegetables and whole grain cereals intake [3-6].

The DIATROFI Program meals were designed based on international guidelines for school-based meals, as well as the Greek National Dietary Guidelines for children and adolescents [7-10]. Apart from the specific Program’s requirements, random laboratory analyses were also conducted to verify the main nutritional parameters (i.e. the ones referred on food labels) [11].

The primary aim of this study is to present the methodology adopted for designing novel school-based food-aid program meals. Τhe secondary aim is to present the methodology adopted for evaluating the nutrient content of the aforementioned meals, as well as ensuring food suppliers’ compliance to meal preparation specifications.

To design the meals distributed by the DIATROFI Program, international age-specific nutritional guidelines were taken into consideration, including the European Food Safety Authority (EFSA) Dietary Reference Values (DRVs) [7], the United States Department of Agriculture (USDA) Nutrition Standards for School Meals [8], and the World Health Organization (WHO) Food and Nutrition Policy for Schools [9]. In addition, the meals were adapted to participating students’ age-specific nutritional needs and the principles of the traditional Greek diet, as detailed in the National Dietary Guidelines for infants, children, and adolescents [10].

Based on the aforementioned dietary guidelines and the existing literature regarding the association between particular nutrient compounds with the occurrence of various acute and/or chronic conditions in both childhood and adulthood, particular emphasis was placed on the fatty acid profile, sodium/salt and added sugars content of meals (Table 1).

*non detectable

**The upper limit for brown sugar addition was set to 5%, whilst in case of honey or a mixture of honey/brown sugar addition the upper limit was set to 8%.

The highest acceptable levels for sodium/salt and added sugars have become stricter throughout the years.

Specifically, poor dietary habits during childhood, including excessive intake of the aforementioned nutrients, have been associated with adverse health effects, such as dental decay, overweight/obesity or elevated risk of chronic non-communicable diseases in adulthood (i.e. cardiovascular disease, type 2 diabetes mellitus, and several types of cancer) [12-14].

The daily meal was composed of a sandwich or traditional savory pie, a dairy product, and fresh fruit(s) (Table 1). The meals were designed according to the following requirements: a) the exclusive utilization of extra virgin/virgin olive oil as the only added source of fat (excluding butter or seed oils), b) the use of >60% whole grain flour, of the total flour used, in all bread/bakery products, c) the avoidance/absence of added preservatives (as all meals were produced within 24 hours of their distribution) and artificial additives, as well as the addition of only the necessary amount of natural additives for meal production, and d) low sodium and sugar content (Table 1). All meals were produced by food suppliers who were selected based on: a) high hygiene/ quality standards, b) inspections for ensuring compliance to food preparation regulations, c) random sampling for evaluating sensory-based characteristics of meals, along with corrective suggestions, and d) financial offers.

In order to ensure compliance with the Program requirements and the nutritional content of meals, unannounced laboratory analyses were conducted in random samples of raw materials, intermediate food products, and ready-to-eat meals. The relationship between the evaluated parameters and the number of violations was examined using the Fisher’s exact test (SPSS v 23).

During the 2013-2016 school-years, 293 laboratory analyses were performed in Accredited (by ISO/IEC 17025:2005) Food Laboratories (Figure 1).

Figure 1: Laboratory analyses applied to verify the nutritional value of meals distributed in the context of DIATROFI Program and the methodology followed in case of violations.

All samples for analyses were: a) received according to required testing standards (e.g., samples sealed upon collection to prevent potential fraud, inclusion of all appropriate codes for complete identification/traceability of food samples) without previous food supplier notification, b) placed into isothermal packs with ice coolers and c) analyzed with official methods. Compliance rate to Program standards was 95.2%, as only 14 violations were detected. According to Fisher’s exact test, the number of violations was not independent of the evaluated parameters (p-value = 0.006).

In particular, the most frequent infringements regarded extra virgin/virgin olive oil adulteration. From 119 total analyses of fatty acids profile (FAME) [15,16] in bread/bakery products, 10 samples were estimated as being “positive for extra virgin/virgin olive oil adulteration” (Figure 1). According to the laboratory report their fatty part contained a mixture of seed oils or vegetable fats without excluding the possible presence of virgin olive oil as well. Since extra virgin/virgin olive oil incurs higher costs than vegetable oils/fats, it is posited that such infringements may have occurred for maximizing suppliers’ financial profit [17]

In addition, sodium/salt content of meals was evaluated through 21 analyses resulting in 3 deviations (Figure 1). The violations referred to: a) a traditional must cookie of the initial sampling before distribution in the participating schools; following laboratory results, recommendations for appropriate corrective actions were implemented; and b) two bakery products having total sodium content marginally exceeding target values, albeit within the accepted standard deviation of ± 20%.

Regarding the added sugar content of meals, 17 analyses were performed and only one violation was observed referring to the aforementioned traditional must cookie (Figure 1). It is of note that Program requirements referred solely to the “added sugar” content of meals. However, taking into account that the analyses estimated the “total sugar content” of the meals, the compliance or violation was estimated based on the laboratory report statement, after taking into account the exact proportion of added sugar reported in the respective food label.

Finally, no deviations were observed regarding dietary fiber, ash or protein content of meals (Figure 1).

In case of detection of infringements and non-compliance with the Program’s strict requirements, financial penalties were imposed upon food suppliers. Further more, respective corrective actions were requested to ensure the high nutritional value of meals. Following appropriate improvements, further laboratory analyses were performed within the context of unannounced inspections, so as to ensure food suppliers’ adherence to the Program’s recommendations. It is of particular importance that in general, compliance with the Program’s specifications was observed, with the incidences of violations being eliminated after the aforementioned process.

The present findings indicate that the novel meals developed within the context of the DIATROFI Program are of high nutritional value and quality, further enhancing not only the impact of food insecurity decrease, but also the improvement of children’s dietary habits. Despite some deviations, the overall observed elevated compliance rates with meal preparation and nutrient content recommendations indicate that this particular school-based food_-aid initiative enables the provision of nutritionally rich meals, designed according to international standards. Compliance to strict specifications appears to be increased when unannounced laboratory analyses of the meals are performed and financial penalties are imposed to suppliers, if necessary. Therefore, the DIATROFI Program may serve as a practical prototype for delivering healthy school-based food_-aid, based on the principles of healthy eating.

The DIATROFI Program research team (in alphabetical order): Belogianni Katerina, MSc; Critselis Elena MPH PhD; Dalma Archontoula, MSc; Giannikou Dafni MSc; Gioti Natalia, BSc; Gryparis Alexandros, PhD; Haviaris Anna Maria, MSc; Karagas R Margaret, PhD; Karnaki Pania, MA; Kastorini Christina Maria, PhD; Kouvari Matina BSc; Linos Athena, MD, MPH, PhD; Linos Constantinos, BSc; Lykou Anastasia, PhD; Markaki Ioanna, PhD; Mitraka Kallis, MA; Pantazopoulou Anastasia, MD, PhD; Papadimitriou Eleni, MD, PhD; Peppas Manolis, BSc; Petralias Athanassios, PhD; Riza Elena, PhD; Saranti Papasaranti Eirini, MSc; Spyridis Ioannis, MSc; Veloudaki Afroditi, MA; Yannakoulia Mary, PhD; Zota Dina, MSc.

The Food_-Aid and Promotion of Healthy Nutrition Program - DIATROFI (http://diatrofi.prolepsis.gr/ ) is implemented by the Institute of Preventive Medicine, Environmental and Occupational Health, Prolepsis. The Program has been approved and runs under the auspices of the Ministry of Education, Research and Religious Affairs. The DIATROFI Program was mainly funded by the Stavros Niarchos Foundation. Over 100 volunteers participate in the DIATROFI Program and deserve our sincere thanks.

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