title: Celiac disease and school food service in Piedmont Region: Evaluation of gluten-free meal.
abstract: The Law 123/2005 recognizes celiac disease as a social disease and so Ministry of Public Health annually allocates specific resources to Regions for managing gluten-free meals in school canteens. Therefore in 2009 Piedmont Region approved a specific project, in collaboration with Food Hygiene and Nutrition Department (SIAN) of several ASL (Local Health Authority), including ASL TO3 as regional leader, and the "Italian Celiac Association - Piedmont and Valle d'Aosta". This project was intended to facilitate the natural integration of celiac people in social life. A retrospective analysis of data has been carried out to assess the management of gluten- free meal of school food services in Piedmont Region in 2010. Furthermore the intervention efficacy has been evaluated comparing the critical points observed in 2010 and 2012.
  
  
  
  The object of the study includes primary and secondary schools that have provided gluten-free food service in Piedmont Region. These school were examined by SIAN staff. (the examination included the check of hygienic aspects and qualitative assessment of the meal). The data were collected using the same checklist throughout the region. All data were included in the unified regional system ("Reteunitaria").
  
  
  
  The results show that 29% of the sampled schools (277) are acceptable in all eight sections (supply, storage, process analysis, equipment check, packaging and transport, distribution of meals, self-control plan and qualitative assessment), whereas 71% are inadequate for at least one of the profiles (60% does not perform the qualitative valuation of service) and in 18% of schools three to seven insufficiencies are observed. Correlations between the number of total insufficiencies and the most critical sections of the check list were performed (with lower scores in "good") such as process analysis, distribution of meals, self-control plan and qualitative assessment. The analysis process has achieved a high score in the field of deficiency for at least 3 parameters. Schools with a good self-control plan have a significant correlation with schools suitable for the analysis process, instead schools appeared insufficient in the process analysis have an increased chance of being insufficient also in the distribution of meals. The schools that provide a transported meal (municipalities highly populated, generally) have many differences in distribution of meals respect schools that prepare food in the school kitchen. In fact, 88% of school that provide a transported meal achieved an appropriate score in distribution of meals section and collected fewer failures in overall assessment than the others. 120 structures are included in the indirect comparison between the checklist's sections with criticisms, during years 2010 and 2012: in 2010 32% of schools were recorded acceptable in all of the eight sections of the checklist and in 2012 this percentage rose to 54%. An improvement can be observed in all areas, but a statistical significant result do not turn out.
  
  
  
  Data show that carry on the control activities of production of gluten free meal in school canteens would be appropriate. Actions focused on improving the methods of preparing meal without gluten were recommended, especially in under populated municipalities with school kitchen on site. The constant presence of ASL staff in school has promoted important changes: cultural change and about the management of allergy and food intolerance. An improvement can be observed: a transition from a suspicion about "special diet" management to an appropriate and responsible management of meals for children and young people suffering from this specific condition.
authors.affiliation: Prevention Department, Complex Structure Service Health Food and Nutrition, ASL TO 3, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Bioletti
authors.affiliation: Prevention Department, Complex Structure Service Health Food and Nutrition, ASL TO 3, Italy.
authors.forename: M T
authors.initials: MT
authors.lastname: Capuano
authors.affiliation: Prevention Department, Complex Structure Service Health Food and Nutrition, ASL TO 3, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Vietti
authors.affiliation: Prevention Department, Complex Structure Service Health Food and Nutrition, ASL TO 3, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Cesari
authors.affiliation: University Hospital Health and Science City of Turin, Hospital CTO, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Emma
authors.affiliation: Chemical Laboratory Chamber of Commerce of Turin, Italy.
authors.forename: K
authors.initials: K
authors.lastname: Leggio
authors.affiliation: Italian Celiac Association of Piedmont, Aosta Valley, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Fransos
authors.affiliation: Prevention Department, Complex Structure Service Health Food and Nutrition, ASL TO 3, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Marzullo
authors.affiliation: Prevention Department, Complex Structure Service Health Food and Nutrition, ASL TO 1, Italy.
authors.forename: S
authors.initials: S
authors.lastname: Ropolo
authors.affiliation: Health Care Directorate, Sector Prevention and Veterinary, Piedmont Region, Italy.
authors.forename: C
authors.initials: C
authors.lastname: Strumia
mesh_terms: D000293:Adolescent; D002446:Celiac Disease / Q000178:diet therapy*; D002648:Child; D055050:Diet, Gluten-Free / Q000592:standards; D005260:Female; D005522:Food Services / Q000592:standards; D006266:Health Education; D006801:Humans; D007558:Italy; D008297:Male; D018673:Nutrition Policy; D009751:Nutritional Requirements; D009752:Nutritional Status; D012016:Reference Values; D012189:Retrospective Studies; D012574:Schools
keywords: Celiac disease; Checklists; Gluten free diet; School cafeteria; Surveillance