Global Forum on Food Security and Nutrition (FSN Forum)

This member contributed to:

    • Alessandra Carè Direttrice Centro di Riferimento per la Medicina di Genere Istituto Superiore di Sanità; Roberta Masella, Prima Ricercatrice; Direttrice Unità di Prevenzione e salute di genere del Centro di Riferimento per la Medicina di Genere Istituto Superiore di Sanità - Roma

      Denise Giacomini, Dirigente medico, Ministero della salute, Segretariato Generale, Ufficio 2

      Monica Gasperini, Psicologa, Ministero della salute, Segretariato Generale, Ufficio 2

      Part 1- Introduction

      5. It should be emphasized that guaranteeing optimal nutrition to women, especially during the reproductive age, represents an effective tool to ensure the health of the entire future generations. It is well known, indeed, that malnutrition affects the fertility and increases the risk of a number of pathologies in the offspring, with consequences also in the adult age.

      1.2 objectives of the guidelines

      10: In this point it should be mentioned that advancing in gender equality positively impact also health of women and girls, facilitate their access to healthcare and maternal health.

      Part 2

      23. Maybe appropriate to change ‘’ to :…… its impact on gender relations, lifestyles, roles and norms

      Part 3


      50/52 Besides the relevance of increasing knowledge and education degree in women and girls, it is of outmost importance to start as early as possible a specific education in health and nutrition. Health literacy is defined as “the degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions”. It is a determinant of health as it favours the adoption of correct lifestyles, the adherence to therapies, and the appropriate access to health services. Furthermore, there is a growing interest about food literacy defined as a set of skills and knowledge related to food, which enables people to make informed choices about food and nutrition for improving their own health. The big challenge, therefore, is to start very early with nutrition education programs to encourage the adoption of adequate lifestyles. School appears to be the most eligible setting to implement strategies aimed at improving people’s diets and food choices that play a pivotal role in promoting health. However, nutritional education interventions in the entire population are mandatory to improve the quality of diet and the knowledge of the nutritional value of different foods.

      3.3.2 it should be merged to 3.3.3, since it is already partly addressed in 63 and it is too general and strictly related to the 3.3.3.

      58: too generic and poorly formulated. Better to include it in 65 ii

      3.3.3 it should include also 3.3.2


      68. ICT and digital devices represent important tools for disseminating information and knowledge. Thus, it should be considered the importance of e-learning to spread health and food knowledge as wide as possible.

      3.5 as general comment is oriented almost entirely to the vegetables and crops production, and barely mentions livestock productions (including game meat). We suggest to expand 91 and 98 including the specific knowledge needed for farming livestock, and the role that women should have as livestock carers, in early detection and control of animal diseases and zoonoses. Moreover, basic educational needs in this sector should also be mentioned, to ensure sustainability, animal health and welfare and to reduce the risk of zoonoses (included those from wild animals and game meat) and epidemics.



      It should be emphasized that consuming a healthy diet play a pivotal role in maintaining not only woman health but in guaranteeing and preserve the offspring health by meeting maternal and foetal needs. Maternal undernutrition, or, in general, malnutrition is a key determinant of infertility, abortion, poor pregnancy, poor perinatal outcomes. Furthermore, the increased risk for non-communicable diseases has been associated with epigenetic regulation of gene expression depending on early life environment, in turn, strongly influenced by maternal diet during pregnancy and also before. Thus, maternal diet by modifying the epigenome, may lead to persistent phenotypic changes and an altered risk for NCDs in later life of the offspring.

      Lastly, concerning gender and nutrition it should be noted that multidisciplinary, multistakeholder and intersectoral interventions can also be carried out through multilateralism actions.

      The G20 Health Forum in the final Declaration of September 2021  underlined that “The COVID-19 pandemic has disrupted people's livelihoods, increased food insecurity and malnutrition and exacerbated inequalities around the world leading to an increase in the levels of poverty, hunger, morbidity and mortality…. Progress towards achieving the SDGs is an important benchmark as we seek to shape a more inclusive and gender-sensitive response for a resilient and sustainable future, where communities in vulnerable situations should be empowered to overcome the long-term negative effects to end of this pandemic and similar effects from future pandemics”.

    • Author of submission (name, surname, position, organization)

      Giuseppe Ruocco, Director General DGISAN - Ministry of Health; Denise Giacomini, Medical doctor, DGISAN - Ministry of Health DGISAN; Elena Sturchio, Res. INAIL/DIT; Elena Carrano Nutritionist, DGISAN- Ministry of Health

      Title of your example

      “Food waste, consumer attitudes and behaviour: a project exploring the reasons linked to consumer-related food waste, involving Italian schools”


      School food and nutrition programs linked to the agricultural sector

      Date, location and geographic scope of your example (regional, sub-regional, national, local)

      Date: 2016- 2017

      National level study in Italy

      Main responsible entity(ies) for the implementation of your example

      Ministry of Health, INAIL/DIT

      Key objectives and implementation approach of your example

      Reducing the amount of wasted food is a key element in developing programs of global environmental and ethical and sustainable food system production. There is a substantial lack in the knowledge of the reasons linked to waste food at households. The aim of the  Project is to focus on the consumption food waste for exploring the reasons of food waste on family level in order to overcome food wasting behavior and point out options to design prevention measures by the responsible involvement in analysis and possible solutions of the students of the “pre University” level, at the same time to point out the need of respecting nutritional rules to not “waste their health”.

      The learning methodology consist of a non-formal and informal education, that offers an experiential learning which aims to achieve knowledge "experimenting."

      The knowledge is shared in a "horizontal" and “multidirectional” relationship among teachers, educators, experts and firstly students, that develop critical attitude of thought and an active participation. Furthermore, the SPAIC project, as well as called in Italy, adopts the "nudging" methodology, also called "gentle push" that can offer a way to behave properly (a kindly suggested model not be not be refused a priori as taxation authority), and therefore effective and culturally acquirable.

      In fact, behavioural economist Richard Thaler and legal scholar Cass R. Sunstein outlined the potential for more innovative and less coercive government interventions to shape people’s behaviour. A central premise behind nudge theory is that people frequently behave in a way that is difficult to predict and not in their own best interest.

      Employing behavioural insights as a prognosticator of human behavioural responses makes it possible to shape behaviours, by changing the” choice architecture” of those people. These changes may prompt people to make better decisions about health, wealth and happiness, in their own declared interest.

      Thaler and Sunstein provide a flexible definition of what a nudge is: “A nudge, as we will use the term, is an aspect of the choice architecture that alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives.

      To count as a mere nudge, the intervention must be cheap and easy to avoid. Nudges are not mandates.

      Nudges can be implemented by a wide range of actors, come in a wide range of forms and seek to achieve a wide range of outcomes. The choice architects are therefore supposed to rearrange the physical and social environment in order to make people change behaviour, a kind of soft paternalism that does not include coercion, a benignly intentioned manipulation meant to improve the direction of peoples’ choices while maintaining freedom of choice.

      Nudge previously has been examined in individual studies for its capacities to positively influence behaviours including decreasing tobacco-use, increasing physical activity and encouraging financial planning instead we’ve decided to use this model in a” wellness based” study on the Food Waste.

      The Project principally consists of two steps:

      1) provide scientific information on "Food waste" that occurs at all stages of the food life cycle

       2) disseminate good behavior model, in efficient and effective way, regarding the issue about food waste and respect of related nutrition rules, among classmates, youngsters and families, in a prevention perspective of the contribution to food waste at households (and the related territory) and at the same time forming a specific conscience of the important role that new generations “have to” play in this field.

      Funding and technical assistance of your example

      Funging of Ministry of Health and technical assistance and expertise of INAIL DIT involving Research Organization (CRF), and three Italian high schools.

      Key stakeholders involved. Describe the cross-sectoral coordination mechanism of your example, if any.

      INAIL/DIT and Ministry of Health/DGISAN are carrying out a Project “Food waste, consumer attitudes and behavior”, involving Research Organization (CRF), and three Italian high schools.

      How your example addresses food security and nutrition challenges. Describe linkages to social protection policies / school food programs / sustainable food systems. 

      The learning methodology consist of a non-formal and informal education, that offers an experiential learning which aims to achieve knowledge "experimenting." The knowledge is shared in a "horizontal" and “multidirectional” relationship among teachers, educators, experts and firstly students, that develop critical attitude of thought and an active participation. Furthermore, the SPAIC project adopts the "nudging" methodology, also called "gentle push" that can offer a way to behave properly (a kindly suggested model not be not be refused a priori as taxation authority), and therefore effective and culturally acquirable.

      Three high schools from Latium region were selected, characterized by different socioeconomic status and fields of education: a private school of art situated in the center of Rome, a Cinematographic high school with a less central location and a biotechnology school in Rome province. We chose different schools to study whether the difference in localization and socioeconomic status has a reflection on habits about food waste (shopping, leftovers, food preservation….) as well as on perception of individual responsibility towards food waste.

      In each school, the activity consists of two steps. In the first step, an analytical review of the specific lifestyles and behaviour of consumer that identify the causes that lead to the production of waste, was performed to transfer the scientific knowledge to a pre-selected group of students involved in the proposed corrective action. In particular, starting from the evidence that the attitudes and behaviour can significantly affect the amount of food directly and indirectly wasted, scientific literature was reviewed to extrapolate the guidelines for achieving the chosen goals, including specific surveys on social media and on the corrective actions already adopted in other case studies.

      After a consultation phase between experts, researchers and professors for the planning of activities, the active involvement of 250 students of Classes 3 and 4th "high school" followed.

      First, data about food waste habits and the perception of one’s responsibility about it were collected with self-report questionnaires, filled in by both adolescents and their families, as a baseline study.

      Lessons regarding food waste impacts on the environment, on loss of resources, on its cause were given to the students, in order to raise awareness of a selected group of students (30 students for each school). Working groups are formed involving students chosen among about 250 of them, considering their "specific" excellence and mainly their interest to the theme, according to teachers involved in the project.

      Teachers and researchers proceeded to organize training activities on food waste, correlating it to the concept of sustainability and underlining its negative economic, environmental and social impacts. The learning methodology consists of both nonformal and informal education, that offers an experiential learning which aims to achieve knowledge "experimenting." The knowledge is shared in a "horizontal" and “multidirectional” relationship among teachers, educators, experts and firstly students, that develop critical attitude of thought and an active participation, through a lifelong learning methodology. The project is planned according to the interests, perceptions and curiosity of the students, focusing on their insights to design useful "products", that transform the idea into concrete social utility tools, according to the European conception of Science useful to the progress and growth.

      During a brainstorming phase, students, teachers and experts, defined objectives, the strategies and the method to be adopted to realise new multimedia viable products to induce correct behaviours regarding food waste. In addition, it is expected to use the WEB as a tool for promotion of strategies and initiatives conducted by the pilot school in the area on food waste in relation to the specificity of their living environment, as a replicable model of education by the schools.

      What are the elements needed for the practice to be institutionally, socially, economically and environmentally resilient and/or sustainable? 

      Reducing the amount of wasted food is a key element in developing programs of global environmental, ethical and sustainable food system production. Food waste occurs at all stages of the food production, starting from harvesting, through manufacturing and distributing and finally consumption, but the largest contribution to food waste occurs surprisingly at home in the developed countries.

      Food waste generation that occurs in large scale retail distribution and at home, is mostly avoidable because large quantities of produced food are discarded when it is still edible. As a cause of negative economic, environmental and social effects, food waste is considered to be one of the priority sustainability issues that needs to be addressed. In developed countries, consumers are one of the biggest sources and they are directly/indirectly responsible of food waste. To successfully reduce consumer-related food waste, it is necessary to have a clear understanding of the factors influencing food waste-related consumer perceptions and behaviours.

      The impact of your example on national policies and people’s lives. What indicators have been used to measure it? 

      In the second step, the objective was to create effective communication products for dissemination of good behavioral practices within the family and territory, enhanced by peer tutoring activities directed to younger class-mates for food waste reduction and environmental and health risk prevention.

      These products may be then widespread through the media channels supported by the researchers. To encourage the students to be aware of their capabilities and achieve effective communication product, the support of expert researchers in the field of "nudging - gentle push" or a psycho-behavioural model it was necessary.

      The model drives the consumers to adopt best practices and good behaviour in daily life.

      In fact, the application of the model aims to change behaviour for reducing food waste and its impacts both on people’s health and on the environment, and it consists of two different kind of nudges: a nudge that involves physical/environmental factors and a nudge based on motivational/emotional factors.

      The environmental nudge consists in the creation of a space inside the school where students may consume meals prepared at home (the lack of a such dedicated space seems to encourage students to buy food at the school bar or from a vending machine placed inside the school that offers foods that are mostly unhealthy and not environmental friendly).

      The motivational/emotional based nudge consist of meetings with a motivator, a person who works with the students at an emotional and creative level to inspire them about their potential to be active participants in choices that are relevant for them and for the whole environment.

      These meeting are designed to make students able to thrust in their capabilities to make important changes in their lives.

      Finally, the dissemination of results will be carried out through the drafting of a final document, and a public presentation of the final results, where students will be the protagonists and actors of the event as well as recipients of the educational process.

      Key lessons (positive and negative) that can be learned from your example and how gaps, obstacles and any other adverse conditions were addressed. 

      The Project has the purpose of raising awareness among young people (a preoccupational category/pre-University studies) and to educate them and to induce correct behaviors regarding wasted food and to become testimonials and possibly “cult” multimedia spreader of correct information and behavior.

      To date, 9 out of 18 months of experimentation are conducted, the Project SPAIC is in progress but has already achieved relevant results.

      We apply a “nudge” approach for enabling and encouraging change in students, families and people in order to overcome food wasting behavior.

      We have not yet objective evidence about results of this model. We have instead just a qualitative analysis from which it seems that the students are very pleased and motivated by both proposals. The purpose of using the Nudge model, in particular the emotional based nudge helped students finding the motivation and the inspiration for the creation of a “product” that can be shaped as they decide, for the purpose of training others to understand the importance of personal actions in global food waste (peer education). Each school is working on a different product chosen by the students according to the specific school orientation and interest.

      From a preliminary qualitative assessment of questionnaires of 30 questions, filled by the students at the beginning of the project, they would seem to have a low sense of responsibility for their own waste.

      However most of the students showed a clear willingness to be informed about environmental negative impacts of food waste.

      Every action of the Project requires the synergistic involvement of the main "actors" (students, teachers, experts and families) called to dialogue and contribute to common goals.

      Following training and emotional meetings, students are producing social – network interactive products or video, for their class mates and youngsters with the intent to disseminate good practices on food waste in environmental and health risk prevention perspective.

      Some of the products realized by students, to date, include leftover food recipes, amusing street interviews, a photo exhibition, the creation of a learning unit on food waste and a script for a short film. After this initial stage there will be other evaluation phases of the project, in order to collect and analyse more data on the development of the project and on the efficacy of the nudge model.

      In conclusion the Project allows to provide education and information about food waste field and health to high school students, and to test by smart indicators the perception of teenagers on this issue. Among the main final purposes of the research we want to evaluate whether the Nudge model can be helpful in this type of study.

      Furthermore we want to understand if the two different nudges used here had some efficacy by comparing the results. At intermediate stage of the project we evaluated that the active involvement of young people in products realization, should be acquired as a standard methodology in order to trigger their inherent ability to innovate in the world of work.

      Sources and/ or additional background material 


      [1] Van der Heijden J. and Kosters M.,2015. From mechanism to virtue: evaluating

      Nudge-theory. RegNet Working Paper, No 80, Regulatory Institutions Network.

      [2] Thaler R. and Sunstein C. , 2009. Nudge (revised edition). London: Penguin.

      [3] Vallgarda S., 2012, A new and better way to improve health?, Health policy 104,


      [4] Missbach B. and Konig J., 2016. Middle choice preference and snack choice: The

      role of self-regulatory resources to nudge healthier food choice, Food Quality and

      Preference 53, 127-131.

      [5] Arno A. and Thomas S.,2016. The efficacy of nudge theory strategies in

      influencing adult dietary behaviour: a systematic review and meta analysis. BMC

      Public Health 16:676.


      MaestraNatura educational program

      Roberta Masella, Antonio D’Amore, Sara Del Papa, Annalisa Silenzi, Elena Carrano, Annamaria Gimigliano, Denise Giacomini

      Since 2012 ISS has been participating in the implementation of an experimental nutrition education project based on the innovative method in science education called MaestraNatura. The teaching method is based on the experiential learning: basic concept of chemistry, physics, biology, biochemistry and physiology are acquired and consolidated through practical activities carried out both at school and at home. By following this path, children learn about the origin and composition of food as well as the chemical and biochemical mechanisms involved in the processes of food transformation and absorption. The project aims at creating the basic knowledge necessary for the understanding and proper application of the nutritional principles contained in the Food Guide Pyramid. The distinctiveness of this approach lies in the educational path direction: it does not start from the knowledge of the Food Guide Pyramid to drive the behavior towards healthy eating, but, on the contrary, it uses the knowledge acquired through experience in the course of a ‘critical period’ eight-year long, namely the years of primary and secondary school, in order to understand the food choices suggested by the Pyramid and the National Guidelines for Healthy Eating. Moreover, it is clear the attempt to focus the attention on health rather than weight, promoting the whole person in every aspects without neglecting the physiological and emotional sphere of children. Consequently MaestraNatura takes in account many of the relevant aspects that should be considered and reconciled in integrated intervention programs aimed at the prevention of obesity and eating disorders.

      Eating behavior develops in response to personal characteristics and genetics as well as physical and social environments. School plays a pivotal role in promoting health and preventing obesity. Although a number of expensive educational programs have been carried out in the last few years in Italy, evidence for the real effectiveness of those school-based programs is quite equivocal. Moreover, contrary to the international literature suggestions, a very limited involvement of parents in these programs have been observed.

      Sperimentare Salute project, designed and managed by Istituto Superiore di Sanità together with Ministry of Health was aimed at implementing, by using MaestraNatura program, a new methodology able to fill the gaps in children knowledge on nutritional issues together with increased engagement of the families. In particular, the project aimed at extending correct knowledge about the origin and function of different food and at using food as a tool to strengthen the relationship between children and parents.

      The innovative educational program MaestraNatura was implemented and tested from 2012 to 2017 in six Italian regions by involving 103 schools, 900 teachers and 21,000 students aged 6-13. As preliminary step, in order to fulfill these objectives, a survey in 25 primary and intermediate schools of Rome was carried out. First of all, 200 teachers were interviewed to know if and how nutritional issues had been presented to the students. It was found that the teachers considered these topics very relevant and dedicated about 4 hours/year to food pyramid-based nutritional program. Secondly, a questionnaire was administered to 3400 children (7-12 years) to evaluate their knowledge on food and nutrition. Results showed a high grade of confusion and misunderstanding and allowed us to elaborate 8 educational and experimental modules (150 hours) specifically aimed at filling those gaps. The didactical content were distributed by a web platform, which also allowed a complete traceability of both school and home activities including cooking.

      Over the last two years we were interested in assessing the effectiveness of MaestraNatura nutrition education program addressed to the students of the last class of primary school and of the second class of secondary-first level schools in filling the gaps in children’s knowledge on food, food processing, adequate nutrition, sustainable nutrition, good lifestyle habits. One hundred and two classes, corresponding to about 2250 students, were enrolled. At the beginning and at the end of the scholastic year, students (n=1000) were required to organize a weekly meal planner; each of them totalized a score that allowed to evaluate possible improvements in their performances. The statistical analyses performed showed that the scores totalized at the end of the didactical path were significantly higher than those at the beginning. MaestraNatura program, thus, might represent a useful new tool for carrying out educational interventions on food and nutrition among children. Furthermore, the web platform represent an economic, fast, and easy-to-use tool for spreading the didactical contents and collecting students’ activities, and also for the transfer of knowledge on those issues to parents, which represents an indispensable stage if changes in behavior are sought after.

      Образовательная программа MaestraNatura

      Роберта Маселла, Антонио Д’Аморе, Сара Дель Папа, Аннализа Силенци, Элена Каррано, Аннамария Джимильяно, Дениз Джакомини

      С 2012 года ISS участвует в реализации экспериментального проекта, посвященного образованию в области питания, который основан на инновационном методе научного обучения под названием MaestraNatura. В основе метода обучения лежит практическое обучение: изучаются основы в области химии, физики, биологии, биохимии и физиологии, которые консолидируются посредством практической деятельности, осуществляемой как в школе, так и дома. Следуя этому пути, дети узнают о происхождении и составе продуктов питания, а также о химических и биохимических механизмах, участвующих в процессах преобразования и усвоения пищи. Проект направлен на создание базовых знаний, необходимых для понимания и правильного применения принципов питания, содержащихся в Пирамиде руководства по питанию (Food Guide Pyramid). Отличительной особенностью этого подхода является направление процесса обучения: он начинается не со знания Пирамиды руководства по питанию, с целью приведения моделей поведения в сторону здорового питания, а, напротив, он использует знания, полученные с помощью опыта в течение «важнейшего периода» в восемь лет, а именно периода обучения в начальной и средней школе, с тем чтобы понять рационы питания, предложенные в Пирамиде, а также в национальных рекомендациях по здоровому питанию. Более того, очевидно, что попытка сосредоточить внимание на вопросах здоровья, а не веса, способствует полноценному развитию человека во всех аспектах, не пренебрегая физиологической и эмоциональной сферами развития детей. Следовательно, MaestraNatura учитывает многие из соответствующих аспектов, которые следует учитывать и согласовывать в рамках комплексных программ вмешательств, направленных на профилактику ожирения и нарушения питания.

      Пищевые привычки развиваются под влиянием личных качеств и генетики, а также физического и социального окружения. Школа играет ключевую роль в укреплении здоровья и предотвращении ожирения. Несмотря на то, что за последние несколько лет в Италии был проведен ряд дорогостоящих образовательных программ, доказательства реальной эффективности этих школьных программ довольно неоднозначны. Более того, вопреки рекомендациям, которые даются в международной литературе, наблюдалось очень ограниченное участие родителей в этих программах.

      Проект Sperimentare Salute, который был разработан Istituto Superiore di Sanità и осуществляется под его руководством в сотрудничестве с Министерством здравоохранения, был направлен на внедрение новой методологии (с привлечением программы MaestraNatura), способной восполнить пробелы в знаниях детей в области проблем питания, а также более активно вовлечь в процесс семьи. В частности, проект направлен на расширение правильных знаний о происхождении и функциях различных продуктов питания, а также об использовании пищи в качестве инструмента для укрепления отношений между детьми и родителями.   

      Инновационная образовательная программа MaestraNatura была внедрена и протестирована с 2012 по 2017 гг. в шести регионах Италии. В процесс были вовлечены 103 школы, 900 учителей и 21000 учеников в возрасте от 6 до 13 лет. В качестве предварительного шага для выполнения этих задач был проведен опрос в 25 начальных и средних школах Рима. Прежде всего, были проинтервьюированы 200 учителей для выяснения того, доводятся ли до внимания учеников вопросы питания и каким образом. Было установлено, что учителя считают эти темы очень актуальными и посвящают около 4 часов в год продовольственной программе на основе пирамиды. Во-вторых, для оценки знаний детей о пищевых продуктах и ​​питании, 3400 детям (7-12 лет) были направлены опросники. Результаты показали высокий уровень путаницы и непонимания, а также позволили нам разработать 8 учебных и опытных модулей (150 часов), специально предназначенных для заполнения этих пробелов. Дидактические материалы были распространены с помощью веб-платформы, что также позволило обеспечить возможность полного отслеживания как школьных, так и домашних мероприятий, включая приготовление пищи.

      В течение последних двух лет мы были заинтересованы в оценке эффективности программы обучения по вопросам питания MaestraNatura, предназначенной для учащихся последнего класса начальной школы и второго класса средних школ, для ликвидации пробелов в знаниях детей о продовольствии, производстве продуктов питания, надлежащем питании, устойчивом питании, привычках правильного образа жизни. Были привлечены сто два класса, насчитывающие примерно 2250 учеников. В начале и в конце учебного года ученики (n=1000) должны были составить еженедельный план приема пищи; каждый из них подсчитывал итог, который позволял оценивать возможные улучшения их результатов. Проведенный статистический анализ показал, что оценки, подсчитанные в конце учебного пути, были значительно выше, чем в начале. Таким образом, программа MaestraNatura может стать полезным новым инструментом для проведения образовательных мероприятий по вопросам продовольствия и питания среди детей. Кроме того, веб-платформа представляет собой экономичный, быстрый и простой в использовании инструмент для распространения дидактических материалов и сбора информации о деятельности, а также для передачи знаний по этим вопросам родителям, что является незаменимым этапом, когда требуются изменения в поведении.

    • Dear All please find enclosed "The Italian National Program of Iodine Prophylaxis"

      proposed by Ministry of Health - DGISAN and OSNAMI - ISS, Rome

      Kind Regards

      Denise Giacomini

      Ministry of Health – DGISAN  (General Directorate for Hygiene, Food Safety and Nutrition) and OSNAMI (Italian National Observatory for Monitoring Iodine Prophylaxis) ISS, Rome

      Date/Timeframe and location
      2017, Italy

      Main responsible entity
      Ministry of Health

      Nutrition context
      The Italian National Program of Iodine Prophylaxis.
      To eradicate iodine deficiency disorders, the World Health Organization (WHO) recommended salt iodization as the preferred strategy. Salt iodization is safe, equitable, largely self-financing and extremely cost - effective.  In Italy, a nationwide salt iodization program on a voluntary basis was implemented in 2005 after the approval of the law n.55/2005 aimed at preventing endemic goiter and other iodine deficiency disorders. According to the Law, iodine is added to course and table salt at 30 mg/kg in the form of potassium iodate and the availability of iodized salt in food shops and supermarkets is mandatory, whereas no iodized salt can be sold only on costumers’ request. Moreover, the law permits the use of iodized salt in the food industry and communal eating areas. In 2009 a nationwide monitoring program of universal salt iodization was implemented and the Italian National Observatory for Monitoring Iodine Prophylaxis (OSNAMI) was established at the Italian National Institute of Health with the aim of evaluating the efficiency and effectiveness of the nationwide program of iodine prophylaxis.

      Key characteristics of the food system(s) considered
      Micronutrient and Food System.
      The recently published WHO guidance on dietary salt consumption in population recommended maximum 5 g/day salt in adults and even less in children 2–15 years of age. However, the WHO promotes both the implementation of programs to reduce population salt intake, as one of the cost-effective strategies to reduce the burden of non-communicable diseases, and universal salt iodization to prevent and control iodine deficiency disorders. An optimal implementation of each program is ensured by promoting their commonalities and complementarities. Commonalities between the two programs are that both are aimed at improving public health; both programs adopt a multi-stakeholder approach and concern health promotion and prevention; both involve working closely with the food industry.

      Over the years, the iodine nutritional status of the Italian population has improved.  Data collected by the Observatory OSNAMI showed that iodized salt sold in 2016 was 60% of all sold salt, whereas it was only 30% in 2005. This increment was essentially due to a multi-stakeholders approach, which implied a proactive involvement of scientific societies and civil associations, particularly the associations of patients with endocrine pathologies. However, despite of the increased sale of iodized salt, data provided by Observatory OSNAMI have recently shown that some Italian regions are still mildly iodine deficient and goiter is still prevalent in these areas.

      Key characteristics of the investment made
      In the last two years, the Italian Ministry of Health, DGISAN, has invested resources for research projects (developed by the Italian National Institute of Health) with the aim to monitor iodine nutritional status of the Italian population and to evaluate regional interventions. Again, the General Directorate for the Hygiene, Food Safety and Nutrition (DGISAN) organized, in cooperation with the Italian National Institute of Health, the first National Consensus Conference on the use of the iodized salt (6th April 2017). During the conference 13 Scientific Societies operating in the field of endocrinology, gynecology, pediatrics, and nutrition signed a POSITION Statement, on the safety of use of iodized salt in adults and children.

      Key actors and stakeholders involved (including through south-south/triangular exchanges, if any)
      The National Coordinating Group promoted this initiative for the Iodine Prophylaxis. This National Group was established at the Italian Ministry of Health (DGISAN) with the aim to provide a national strategy of the nationwide program of iodine prophylaxis. In the past iodine prophylaxis was an issue almost exclusively covered by endocrinologists because iodine deficiency disorders are frequently thyroid disorders, especially goiter which is the most frequent consequence of iodine deficiency.

      Key changes (intended and unintended) as a result of the investment/s
      With the signature of the aforementioned Position Statement, iodine prophylaxis in our country has become “a field of action” also for gynecologists, pediatricians and nutritionists.

      Challenges faced
      For the future, to improve the iodine nutritional status of the population and to simultaneously reduce population salt intake, DGISAN foresees to involve the food industry and the communal eating areas more actively, upon the principle of a multi-sectorial and multi-stakeholders approach, as recommended by WHO. In fact, recent data of the Observatory OSNAMI have shown that the use of iodized salt is less than 10% in the food industry and about 25% in the communal eating areas. These low percentages imply that the iodized household salt is still the major contributor to iodine intake in our country. Since in industrialized countries only 10-20% of the consumed salt is household salt, whereas most of the daily salt intake is due to salt used in food production, it will be critical to convince the food industry to use iodized salt in their products to successfully correct iodine deficiency in Italy.

      Lessons/Key messages
      According to these WHO recommendations, in the last years DGISAN and OSNAMI have implemented policies to synergize salt reduction and iodine fortification strategies. Currently these are focused on: i) the engagement of different  departments in support of universal salt iodization and effective policies and regulations to reduce salt consumption; ii) communication to population by promoting campaigns  sharing messages emphasizing the importance of reducing salt and optimizing iodine intake.