Italy provides an unusually interesting setting for this kind of research. National guidelines establish standards for school catering, but the country’s highly decentralized governance means that responsibility for meal quality, supplier selection, and stakeholder engagement is dispersed across municipalities and regions. The result is a patchwork: two schools in different towns, or even in different neighborhoods of the same city, can operate under markedly different rules, budgets, and catering arrangements. This variability is precisely what makes Italy a natural laboratory for studying how different dimensions of the school food environment relate to children’s diets, because the differences between schools are real, structural, and measurable rather than hypothetical.

The research team, led by Veronica Vitali, Giulia Tiboldo, Alessandro Varacca, and Elena Castellari of the Università Cattolica del Sacro Cuore, designed a questionnaire that probed five broad areas of the school food environment: governance, infrastructure, food provision, educational activities, and family engagement. Teachers, who observe children’s eating habits daily and often participate in mealtime supervision, served as informants about both the characteristics of their schools and the consumption patterns of their students. The survey captured details such as the types of meals offered, the presence of school gardens and kitchen facilities, the involvement of parents and local stakeholders in food decisions, and the frequency of nutrition-related educational activities.

One of the study’s most technically interesting features is its analytical approach. Rather than treating each questionnaire item as a standalone measure, the researchers used Item Response Theory, a family of statistical models originally developed in psychometrics, to construct three latent indices. The first, quality of the offer (QO), captures the overall quality of the food provided by the school. The second, quality of educational activities (QA), measures the richness and frequency of nutrition education. The third, role of stakeholders in governance (RSG), quantifies how actively parents, teachers, and other actors participate in decisions about school food. Latent indices of this kind are valuable because they aggregate many noisy individual indicators into a single, more reliable score, reducing measurement error and allowing researchers to compare schools along meaningful dimensions.

With these indices in hand, the team turned to ordinal logistic regression, a statistical technique suited to outcomes that fall into ordered categories, such as low, medium, and high consumption of a given food group. The models estimated how the three indices, together with school-level characteristics like school type and location, were associated with teacher-reported consumption of fruit, vegetables, and legumes. The sample itself was diverse: sixty percent of respondents taught in kindergartens, sixty-three percent worked in urban areas, and the split between state-recognized private schools and public schools was nearly even, at fifty-four and forty-six percent respectively. This breadth strengthens the case that the patterns observed are not artifacts of a single school type or region.

The headline result concerns the quality of the offer. Across all three food groups, the QO index showed the strongest and most consistent associations with teacher-reported consumption. In other words, schools where the food provision itself scored higher, encompassing the quality and characteristics of the meals served, were also the schools where teachers reported that children ate more fruit, vegetables, and legumes. This is a deceptively simple finding with potentially large implications: it suggests that what schools actually serve may matter more for children’s diets than the educational programming wrapped around it. Children, it seems, respond to their food environment in a fairly direct way, and improving the plate may be the most reliable route to improving the diet.

Governance also emerged as a meaningful factor, though with more modest effect sizes. Higher scores on the stakeholder governance index were associated with a probability of high vegetable consumption higher by 2.5 percentage points, and a probability of high legume consumption higher by 2.0 percentage points. While these shifts may sound small, in a population-level intervention context even a couple of percentage points across an entire school system can translate into substantial changes in dietary intake. The finding aligns with a growing body of work on participatory food governance, which argues that when parents, teachers, and communities have a genuine voice in school food decisions, the resulting environments better reflect local needs and sustain higher standards over time.

Perhaps the most striking negative result involves nutrition education. The quality of educational activities index showed no significant association with consumption of any of the three food groups. For anyone who has assumed that teaching children about healthy eating is the key to changing what they eat, this is a sobering data point. The study does not claim that education is worthless; rather, it suggests that, at least as measured in this survey and in the Italian context, structural and governance-related dimensions of the school food environment carry more weight than classroom-based nutrition activities. It is a finding that echoes a broader theme in behavioral science: environments often shape behavior more powerfully than information does, and a child who is served high-quality meals daily may internalize healthy eating patterns regardless of how many nutrition posters hang in the hallway.

School type mattered as well. Kindergartens showed higher quality-of-offer scores, by 0.132 on the latent scale, compared with primary schools, and children in kindergartens were associated with higher probabilities of high fruit consumption, by 4.0 percentage points, and high legume consumption, by 6.9 percentage points, relative to their primary school counterparts. This pattern is consistent with developmental research showing that early childhood is a critical window for establishing food preferences, and it hints that the Italian system may do a better job of feeding its youngest students than its older ones. Whether the advantage reflects stricter catering standards for younger children, more attentive mealtime supervision, or simply age-related differences in eating behavior is a question the authors flag for future work.

The study’s authors are careful about the limits of what can be concluded. The data are cross-sectional and rely on teacher reports rather than direct dietary measurement, so the associations described cannot be read as causal effects, and the relationships may evolve over time. Still, the research makes a substantive contribution to ongoing debates about school meal governance and public food procurement, particularly in decentralized systems like Italy’s where national guidelines coexist with wide local variation. As policymakers across Europe and beyond grapple with how to build healthier and more sustainable food systems, the Italian evidence offers a clear directional signal: invest in the quality of the food itself and in the engagement of the people who govern it, and treat nutrition education as a complement rather than a substitute. The lunch tray, it turns out, may be the most important classroom in the school.

Subject of Research: The association between school food environment quality, governance, and children's fruit, vegetable, and legume consumption in Italian schools

Article Title: School food environment and healthy eating in Italian schools: evidence from a nationwide teacher survey

Article References: Vitali, V., Tiboldo, G., Varacca, A., & Castellari, E. (2026). School food environment and healthy eating in Italian schools: evidence from a nationwide teacher survey. BMC Public Health. https://doi.org/10.1186/s12889-026-29605-1

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29605-1

Keywords: school food environment, school meals, children's dietary behaviors, school food governance, Item Response Theory, Italy, public health, nutrition education, fruit and vegetable consumption, public food procurement, BMC Public Health, kindergarten

The study team assessed the food environments of 24 upper secondary schools using a validated food retail environment assessment protocol. Their audit covered both the school canteens themselves and 100 food retail outlets operating in the immediate vicinity of the schools, capturing a total of 124 retail settings. This dual approach matters because adolescents do not eat exclusively at school; they move fluidly between the canteen counter at morning break and the corner shop on the way home. By measuring both settings with the same instrument, the researchers could ask whether the canteen, the surrounding shops, or some combination of the two is the more meaningful driver of dietary behavior. The audit recorded what foods were available, how much shelf space each category occupied, how products were priced relative to one another, and what kinds of advertisements appeared on walls, counters, and windows.

The marketing findings were among the most dramatic in the study. The researchers identified 530 food advertisements across the audited settings, 499 of them in the surrounding food retail outlets and 31 in the school canteens. When each advertisement was evaluated against the World Health Organization’s Eastern Mediterranean Region Nutrient Profile model, known as the WHO-EMR-P, a staggering 90.8 percent of advertisements in the food retail outlets and a full 100 percent of those inside the canteens were classified as non-permissible. In other words, essentially every food advertisement a student in Shiraz encounters in and around school promotes a product that fails the regional WHO standard for marketing to children. For a population of minors, the sheer saturation of non-permissible marketing represents a policy failure that no single school can address alone, since the overwhelming majority of the advertising burden sits just outside the school walls in privately operated shops.

To connect these environmental measurements to actual behavior, the researchers assessed dietary intake in 656 students using a validated 90-item Food Frequency Questionnaire, and they collected anthropometric measurements, including indicators of body composition, at the same time. Because the students were minors, written informed consent was obtained from their parents before enrollment, and the study was approved by the Ethics Committee of Shiraz University of Medical Sciences. The analytical strategy relied on mixed-effects models, a statistical framework well suited to this kind of nested data, in which individual students are clustered within schools. This approach allowed the researchers to estimate the association between each school-level food environment characteristic and each student’s intake while accounting for the fact that students in the same school share a common environment and are therefore not fully independent observations.

The headline result is that availability emerged as the most consistent predictor of what students ate. Greater availability of a given food category was associated with higher intake of that same category across a remarkably broad range of products. The effect was statistically significant for healthy dairy products, with a coefficient of 3.291 and a p-value of 0.008, and it held for unhealthy dairy products as well, with a coefficient of 6.737 and a p-value of 0.042. Unhealthy cakes and biscuits showed a coefficient of 1.428 with a p-value of 0.002, one of the strongest associations in the dataset. Beverages, chips and puffs, and sweets each also displayed significant positive associations, with coefficients of 0.403, 0.090, and 0.175 respectively. The pattern is intuitive but consequential: when a food category commands more shelf space in the canteen or the shops nearby, students consume more of it, whether the category is one that nutritionists would applaud or one they would warn against.

Just as notable is what did not predict intake. Food prices, despite the considerable attention that pricing interventions such as sugar taxes and subsidy schemes receive in the public health literature, were not significantly associated with dietary intake in this sample. The researchers did observe that price differences varied across food groups, with unhealthy products being more expensive in some categories and less expensive in others, suggesting that the price landscape around Shiraz schools is heterogeneous rather than uniformly favoring cheap junk food. Yet that heterogeneity did not translate into measurable differences in what students reported eating. Similarly, advertising density showed a more limited footprint than availability, reaching statistical significance only for healthy ready-to-eat foods, with a coefficient of 0.711 and a p-value of 0.049, and for simple sugars, with a coefficient of 3.054 and a p-value of 0.015. The association with simple sugars is consistent with the concern that heavy marketing of sugary products drives consumption, but the overall advertising signal was far weaker than the availability signal.

Perhaps the most sobering finding for anyone hoping that a single environmental lever could transform adolescent health is that no school-level food environment indicator was associated with overall nutritional intake or with anthropometric outcomes. Body measurements, in other words, did not shift in detectable ways with the characteristics of the food environment that the study measured. This null result should be interpreted carefully rather than dismissively. Cross-sectional designs capture a single moment in time, and anthropometric outcomes such as body mass index reflect years of accumulated energy balance, genetic factors, physical activity, household food environments, and socioeconomic circumstances that a school-based audit cannot disentangle. A student’s weight at age sixteen is the product of a lifetime of exposures, most of which occurred long before the research team arrived with their measurement protocol. The absence of an anthropometric association does not mean the food environment is irrelevant to obesity; it means that the pathway from shelf space to body size is long, buffered, and difficult to detect in a snapshot.

The technical architecture of the study deserves attention because it illustrates the methodological machinery behind modern food environment research. The distinction between school canteens and food retail outlets as separate strata, the use of shelf space as a continuous measure of availability, the application of the WHO-EMR-P nutrient profile as an external, standardized benchmark for classifying advertisements as permissible or non-permissible, and the use of mixed-effects regression with appropriate attention to multiple testing all reflect a maturing field that has moved beyond simply counting fast food restaurants near schools. The researchers also employed false discovery rate control, a statistical correction that reduces the risk of spurious findings when many associations are tested simultaneously, lending additional credibility to the associations that survived. The 90-item Food Frequency Questionnaire, meanwhile, allowed intake to be analyzed at the level of food groups rather than single nutrients, which is the level at which food environment interventions actually operate.

The authors conclude that school food environments in Shiraz were characterized by a predominance of unhealthy foods and widespread unhealthy food advertising, and they argue that strengthening and monitoring food environment policies in and around schools may help improve the availability and promotion of healthier options. The emphasis on monitoring is significant. A policy that restricts what a canteen may sell does nothing, on its own, about the 100 food retail outlets surrounding the schools or the 499 non-permissible advertisements displayed in them. Effective regulation of the school food environment therefore has to extend beyond the school gate, a lesson that jurisdictions from Chile to the United Kingdom have learned through mandatory front-of-pack labeling laws, zoning restrictions on fast food outlets near schools, and statutory limits on the marketing of high-fat, sugar, and salt products to children. The Shiraz data suggest that in this setting, such measures would be attacking an environment in which nearly nine out of every ten advertisements a student sees fail the regional WHO standard.

For the broader scientific conversation, the study contributes a clear hierarchy of environmental influence. Availability, measured as the physical presence and shelf space of food categories, behaved as the workhorse variable, consistently tracking with intake across healthy and unhealthy categories alike. Pricing, in this particular market context, did not. Advertising mattered for some categories but not others. None of the three levers moved the needle on body measurements in a cross-sectional frame. That hierarchy gives policymakers a practical ordering: if the goal is to change what adolescents eat today, changing what is on the shelves is the intervention with the strongest evidentiary support from this study. If the goal is to change what adolescents weigh, the evidence base remains far more complex, and school food environments are likely only one thread in a much larger fabric of determinants. The study, funded by Shiraz University of Medical Sciences and published open access, adds an important data point from a region of the world where such granular environmental audits have historically been scarce, and it underscores a simple truth that resonates far beyond Iran: adolescents eat what is put in front of them, and right now, what is put in front of them is overwhelmingly unhealthy.

Subject of Research: Associations between school food environment characteristics and adolescents' dietary intake and anthropometric outcomes

Article Title: Associations of school food environment characteristics (availability, pricing, and marketing) with adolescents’ dietary intake and anthropometric outcomes

Article References: Associations of school food environment characteristics (availability, pricing, and marketing) with adolescents’ dietary intake and anthropometric outcomes. (n.d.). https://doi.org/10.1186/s12889-026-29686-y

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29686-y

Keywords: adolescent health, school food environment, dietary intake, food availability, food advertising, food pricing, school canteen, obesity, BMC Public Health, Iran, WHO nutrient profile, public health nutrition