Food aid and healthy nutrition programmes in schools: what works?

Child eats watermelon

What is the best way to reduce food insecurity and obesity in schools? That’s one of the main questions studied by the DIATROFI programme. Since 2012 more than 110,000 students in 650 schools have taken part in the programme. They are helping the research team to understand the effectiveness of, for example, distributing healthy meals compared to vouchers, and study what has the biggest benefit: healthy meals, education, or both? Here are the results.

By Afroditi Veloudaki, Ioannis Koutelidas, Athanassios Petralias and Athena Linos, on behalf of the DIATROFI programme research team.

In a previous edition of this magazine, we introduced the DIATROFI programme, a large-scale food aid and healthy nutrition school-based programme implemented by the Prolepsis Institute (Greece) since 2012. As of today, more than 110,000 students in 650 schools have been receiving a healthy daily meal and nutrition education through the programme.

Besides the food aid and educational benefits to the participants, one of the main targets of the DIATROFI programme is the promotion of public health. We are implementing and validating some of the international best practices which aim to reduce food insecurity and obesity. To do this, we designed, developed, and conducted a large-scale research study that includes quantitative and qualitative analysis methods with the use of validated tools and incorporating randomised control trials. For the DIATROFI study, more than 166,000 questionnaires have been collected and analysed and more than 480 focus groups and personal interviews have been conducted (Table 1).

Table 1: Data collected in the framework of the DIATROFI programme during the years 2012-2018

The methodology

The quantitative study is conducted via validated questionnaires which are distributed to parents at the start and at the end of each school year. The questionnaires allow us to measure the improvement before and after the implementation of the programme, for each year and student, in variables such as food insecurity, food consumption and patterns, adherence to Mediterranean diet, health related quality of life, body mass index, educational indices, and others (Table 2). In addition, during several school years we have collected additional data related to school culture and access to health care services, as well as questionnaires assessing the programme from the perspective of school teachers and the school canteen owners.

The qualitative study looks at understanding the behaviour and the perceptions of participants towards the programme, the assessment of the efficiency and impact of the programme, and the improvement on a continuous basis of the DIATROFI program’s features. The qualitative study is conducted via focus groups and personal interviews with parents, students and teachers. The Krueger method is used and two interviewers are undertaken per session.

Table 2: Questionnaires completed by the students’ parents at the start and the end of each school year

Three studies

In addition, during the school years 2011-2012, 2013-2014, and 2014-2015 three important randomised cohort studies were conducted. In the first study (April-June 2012) two alternative food aid methods were compared in 34 schools. The first method involved distributing daily healthy meals to students as opposed to distributing food vouchers of equal value to the parents, in order to purchase healthy foods from local supermarkets. The distribution of healthy meals to the students was found to be more beneficial in terms of reducing food insecurity and improving eating habits among students, reducing childhood obesity, and improving the behaviour of students in school.

In the second study (October 2013-June 2014), 146 schools were randomised into those for which students were receiving a healthy daily meal and an educational programme on healthy nutrition, and students receiving only the daily meal. Results showed that the multicomponent intervention (healthy meal and educational activities) is a more effective strategy to improve dietary habits and reduce childhood obesity.

In the third study (October 2014-June 2015), 80 schools were randomised to those in which children were receiving a healthy daily meal and educational activities, and those receiving only educational activities. The results showed that the reduction in food insecurity – although significantly larger amongst those receiving the multicomponent intervention – was also observed to a smaller degree amongst those receiving only the educational programme.

These studies highlighted the importance of combing food aid through the distribution of daily healthy meals at school with an educational program on healthy nutrition. This is the most effective practice to reduce food insecurity and childhood obesity, and to improve students’ dietary habits, educational activity, and health related quality of life.

More than 36 scientists from world recognised universities have participated In the DIATROFI study. They have come from various disciplines, such as medicine, public health, epidemiology, statistics, economics, nutrition science, food technology, biology, and more. The scientific output of the DIATROFI study currently includes 14 publications in international and national scientific journals and series, and 36 presentations in international and national scientific seminars and workshops.


Indicative publications of the DIATROFI study:

  1. Effectiveness of a school food aid programme in improving household food insecurity; a cluster randomized trial. Dalma A, Petralias A, Tsiampalis T, Nikolakopoulos S, Veloudaki A, Kastorini C-M, Papadimitriou e, Zota D, Linos A, on behalf of the DIATROFI Program Research Team. European Journal of Public Health, ckz091, May 2019, https://doi.org/10.1093/eurpub/ckz091
  2. “Daily distribution of free healthy school meals or food-voucher intervention? Perceptions and attitudes of parents and educators.” Dalma A, Zota D, Kouvari M, Kastorini CM, Veloudaki A, Ellis-Montalban P, Petralias A, Linos A, Belogianni K, Critselis E, Georgakopoulos P, Haviaris AM, Karagas RM, Karnaki P, Linos C, Lykou A, Markaki I, Mitraka K, Pantazopoulou A, Papadimitriou E, Peppas M, Riza E, Papasaranti ES, Spyridis I, Yannakoulia M. Appetite, 120, January 2018, pp. 627-635.
  3. “Policy brief addressing food insecurity and obesity Case study: the DIATROFI program.” Veloudaki A, Petralias A, Zota D, Karnaki P, Dalma A, Riza E, Linos A. European Journal of Public Health, 26 (suppl. 1), November 2016, ckw169.005.
  4. “The influence of a school-based intervention program regarding adherence to a healthy diet in children and adolescents of disadvantaged areas in Greece: The DIATROFI Study”. Kastorini CM, Lykou A, Yannakoulia M, Petralias A, Riza E, Linos A on behalf of the DIATROFI Program Research Team. Journal of Epidemiology & Community Health, 70(7), July 2016, pp. 671-677.
  5. “Promotion of healthy nutrition among students participating in a school food aid program: a randomized trial” Zota D, Dalma A, Petralias A, Lykou A, Kastorini C-M, Yannakoulia M, Karnaki P, Belogianni K, Veloudaki A, Riza E, Malik R, Linos A. International Journal of Public Health, 61(5), June 2016, pp. 583-592.
  6. “Perceptions of parents and children, participating in a school-based feeding program in disadvantaged areas in Greece: A qualitative study”. Dalma A, Kastorini C-M, Zota D, Veloudaki A, Petralias A, Yannakoulia M, Linos A. Child: Care, Health & Development, 42(2), March 2016, pp. 267-277.
  7. “The impact of a school food aid program on household food insecurity” Petralias A, Papadimitriou E, Riza E,Karagas RM, Zagouras A, Linos A on behalf of the DIATROFI Program Research Team. European Journal of Public health, 26(2), February 2016, pp. 290-296.
  8. “Socio-economic and lifestyle parameters associated with diet quality of children and adolescents using classification and regression tree analysis: The DIATROFI study”. Yannakoulia M, Lykou A, Kastorini C-M, Saranti Papasaranti E, Petralias A, Veloudaki A, Linos A. Public Health Nutrition, 19(2), February 2016, pp. 339-347.

Acknowledgements

Over 200 volunteers participated in the DIATROFI Program and deserve our sincere thanks. 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, and has been approved and conducted under the auspices of the Greek Ministry of Education and Religious Affairs. Founding donor of the DIATROFI Program is the Stavros Niarchos Foundation.

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

DIATROFI Programme Research Team
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This article was written by Afroditi Veloudaki, Ioannis Koutelidas, Athanasios Petralias and Athena Linos, on behalf of the DIATROFI programme research team.

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