7.4 Healthy lifestyles and healthy nutrition
In Italy, the main tools for promoting health and well-being are represented by the National Plan for Prevention (PNR) and the Government Program “Guadagnare Salute: rendere facili le scelte salutari”. These are tools that promote healthy lifestyles and proper nutrition. They are aimed at the entire population and specifically they are addressed at children, adolescents and young adults through prevention and health promotion programs.
The National Prevention Plan (PNP), whose coordination is entrusted to the Ministry of Health, is an integral part of the National Health Plan. Established in virtue of the agreement between the State and the Regions (23 March 2005), it deals with issues concerning health promotion and disease prevention and requires each Region to prepare and approve its own Regional Plan of prevention (PRP). The PNP has a duration of four years. The one drawn up for the 2014-2018 period to which the Regions and Autonomous Provinces have allocated €200 million, has been extended to the whole of 2019 and outlines a system of health promotion actions and prevention, which accompany the citizen in all phases of existence in the places of life and work, with specific objectives aimed at young people. The plan identifies the following 10 macro-objectives:
- reducing the preventable and avoidable load of morbidity, mortality and disability of non-communicable diseases;
- preventing consequences of neurosensory disorders;
- promoting mental well-being in children, adolescents and young people;
- preventing substance addiction;
- preventing road accidents and reducing the severity of their outcomes;
- preventing domestic accidents and their outcomes;
- preventing accidents and occupational diseases;
- reducing potentially harmful environmental exposure;
- reducing the frequency of priority infections/infectious diseases;
- implementing the National Integrated Control Plan for food safety and veterinary public health prevention.
The PNP is accompanied by an evaluation plan State-Regions Agreement Rep. Acts no. 56 / CSR of 25 March 2015 which aims to: measure the impact it produces on the health on a central, regional and local level as well as ensure national cohesion in achieving the health goals.
Each Region formulates a Regional Logical Framework (QLR), which defines the programs, actions, beneficiaries and process indicators (and related standards) with which it intends to implement the national strategies and monitor their implementation.
For the 2014-2018 PNP, €300,000 have been allocated. A part of the evaluation system aims, through the definition by the Regions of “sentinel indicators”, to certify compliance with the commitments undertaken at the regional level and the obligations deriving from the system to verify LEA compliance. More than 130 central indicators have been defined, covering all the objectives of the PNP, with relative standards for 2018, which the Regions must aim for through the Regional Plans, setting the corresponding standards in the Assessment Document.
On 6 August 2020, with an agreement in the State-Regions Conference, the PNP 2020-2025 was adopted.
It strengthens the vision that considers health as the result of a harmonious and sustainable development of the human being, nature and the environment (One Health). Recognizing that the health of people, animals and ecosystems are interconnected, it promotes the application of a multidisciplinary, intersectoral and coordinated approach to address any potential or existing risks that originate from the interface between environment-animals-ecosystems. The PNP 2020-2025 aims to contribute to the achievement of the objectives of the United Nations 2030 Agenda, which defines a combined approach to the economic, social and environmental aspects that impact on the well-being of people and on the development of societies, thus addressing the fight against health inequalities as a priority across all objectives.
The Plan is divided into six macro-objectives:
- Chronic non-communicable diseases;
- Addictions and related problems;
- Road and domestic accidents;
- Accidents and accidents at work, occupational diseases;
- Environment, climate and health;
- Priority infectious diseases.
The financial allocation for the 2020-2025 PNP is €200 million annually bound within the budget of the National Health System.
With regard to the verification of the PNP 2020-2025, the following program has been prepared: by March 31 of each year (2023-2026), the Regions are required to document the progress of the Plan.
For the year 2020, the evaluation is successful in the presence of the regional act of transposition of the agreement; for the year 2021, the evaluation is successful if the regional planning meets the set objectives; for the years 2022-2025, the evaluation is successful if it shows a growing proportion (60% in 2022, 70% in 2023, 80% in 2024, 90% in 2025) of the total indicators.
The coordination of the implementation of the National Prevention Plan 2020-2025 is entrusted to the Ministry of Health, Directorate General of Health Prevention, which ensures the necessary operational link with the other Directorates General of the Ministry involved.
The national program “Gaining health: making healthy choices easy” was adopted with DPCM May 4, 2007 and its purpose is to promote lifestyles that can counteract, in the long term, the burden of chronic diseases and that can make citizens gain years of healthy life. It is the program that Italy has adopted to promote health as a collective benefit, the coordination tool of the Gaining health actions is the “National Platform on nutrition, physical activity and smoking”, a technical committee that operates at the Ministry of Health and ensures the connection between the institutions. It also defines the overall guidelines and annually establishes the program’s priorities.
The program aims to tackle the four main health risk factors (smoking, alcohol abuse, poor diet, physical inactivity) in an integrated way to ensure a fairer and healthier society as well as reduce health disparities within the population groups, focusing action on health promotion, not only through interventions aimed at strengthening the capacities of individuals (empowerment), but also through interventions aimed at changing life contexts.
There are 4 specific projects that develop the government program:
- Gaining health by making a healthier diet easier (nutrition)
- Gaining health by making it easier to move around and exercise (physical activity)
- Gaining health by making it easier to be smoke-free (anti-smoking)
- Gaining health by making it easier to avoid alcohol abuse (fight against alcohol abuse).
“Gaining health” works through alliances and agreements that involve different subjects, sectors and responsibilities at an institutional level (Ministry of Health, Department of Family Policies, Department of Equal Opportunities, Department of Youth Policies, Ministry of Agricultural Food Forestry Policies, Ministry of Education, Ministry of Economic Development, Ministry of Economy and Finance, Ministry of Transport, Ministry of Environment, Ministry of Labour, Ministry of University and Research; Higher Health Institute, Higher Prevention Institute e Work Safety, National Institute for Food and Nutrition Research; Regions, Provinces, Municipalities), along with the most significant associations, business and trade union organizations.
The program promotes the use of surveillance data for the planning, implementation, monitoring and evaluation of health programs, to ensure the accountability of prevention.
The surveillance programs activated in relation to the younger groups are:
1. OKkio alla Salute: project, with the direct involvement of the Regions, for the realization of a system of surveys on some anthropometric parameters, on the eating habits and physical activity of primary school children (6-10 years), linked to the European program Guadagnare salute and National prevention plan. OKkio alla Salute is part of a broader project of the National Center for Disease Prevention and Control (CCM), or the “System of investigations on behavioral risks for ages 6-17”, promoted by the Ministry of Health and the Ministry of Public Education, for which the ISS received a loan of €1,800,000. The implementation of the project is entrusted to the Regions and the Local Health Authorities, in collaboration with schools, and the coordination to the National Centre for epidemiology, surveillance and health promotion (Cnesps) of the Istituto Superiore di Sanità (Iss) assisted by the Regional School Office for Lazio, which handles relations and communications with the Regional School Offices and schools. The methods of carrying out the project include:
- recording of the anthropometric measurements of primary school pupils (weight and height);
- collection of information on the school environment, on training activities relating to physical activity and nutrition, carried out by the school independently or in collaboration with other institutions;
- collection of information on eating habits, physical activity and sedentary lifestyle by primary school pupils, carried out through a simple questionnaire filled in by children in the classroom;
- collection of information on children's eating habits, physical activity and sedentary lifestyle, carried out through a questionnaire addressed to parents.
In a second phase, the project provides for the creation of information support for schools to guide them towards the most effective interventions in favour of the promotion of children’s health.
- HBSC - Health behaviour in school-aged children
This is an international multicentre study carried out in collaboration with the Regional Office for Europe of the World Health Organization (WHO), which was created as part of the project “Survey system on behavioural risks in the age of 6-17”. HBSC turns its attention to a sample of boys (both boys and girls) of school age: 11, 13 and 15 years. HBSC surveillance is managed by a network of university researchers and government institutions coordinated by a committee made up of elected members of the countries represented. The main objective of the survey is to increase knowledge of the determinants of health and well-being of adolescents in order to better guide the (national and international) health prevention and promotion policies aimed at young people. For the surveys, a closed-ended questionnaire is used which is administered to the children of the sampled schools and which is composed of a part common to all countries and optional in-depth sections that each participating State can decide to include on the basis of particular interests ata a national level. The questionnaire addressed to young people is made up of questions that investigate various aspects:
- health-related behaviours (with particular reference to nutrition, oral hygiene, physical activity and sedentary lifestyle, consumption of alcohol, tobacco and substances, gambling, sexual behavior, violence suffered, to perceived well-being);
- individual health and well-being
- the social context
- the environmental context for the development of relational skills.
The school context is also the subject of study and in-depth analysis: through a questionnaire addressed to the head teacher, useful information about the school is collected both in terms of initiatives and programs to promote health and in terms of the adequacy of the infrastructures.
For the data emerging from the HBSC study, see paragraph 7.1.
In 2018 the Emilia Romagna region joined the international multicentric study HBSC on behaviours connected with health in boys and girls in school age, with a sample of 1200 people. The Region has also organized a webinar during which data from 2021 were presented “Health and lifestyle of young Italian people between 11 and 15 years old”, related with the study from 2018. It was considered as representative for the national and regional scenario, giving back the picture of the single local realities.
In April 2022 there will be the HBSC survey 2022, important for understanding what happened during the pandemic years: the comparison between the data collected in 2018 and the new ones will be a key to detect new health needs and areas of intervention.
2.Encourage healthy lifestyles and healthy nutrition in young people
In 2018, the Council for Agricultural Research and Analysis of the agricultural economy (CREA) published the “Guidelines for a healthy”, with the purpose of providing consumers with a series of simple information and indications to eat better and with taste, in compliance with the food traditions of their country while protecting their health. The study provides important tips on weight control, the importance of physical activity, salt reduction, alcohol avoidance and sugary drinks, macronutrients, water and the necessity of having a varied diet.
The surveillance, promoted by the Ministry of Health /Centre of control and prevention of diseases (CCM) is coordinated by the college of health (ISS) together with the Universities of Turin, Padua and Siena and is carried out in collaboration with the Ministry of Education of the University and Research, the Regions and the Local Health Authorities;
A working table for the prevention and contrast of overweight and obesity was set up at the Directorate-General for Health Prevention. It has the task of providing a national strategic policy document aimed at defining effective strategies and actions to fight the spread of obesity and encourage informative, formative and sensibilization initiatives, among other things, to spread awareness on the risks of obesity resulting from an incorrect, unbalanced and excessively caloric diet, especially in young people and adolescents.
Italy has introduced some provisions to ensure greater protection from smoking for minors.
These measures include: a ban on the sale of new-generation tobacco products to minors, a ban on smoking in vehicles in the presence of minors and pregnant women, a ban on smoking in the external
areas of paediatric hospitals and scientifically-based hospital and care institutions, as well as in the external areas of individual paediatric, gynaecological, obstetrics and neonatology departments, stricter penalties for the sale and administration of tobacco products, electronic cigarettes and new-generation products to minors, verification of vending machines, in order to ensure the correct age of the purchaser.
It is designed to fight the habit of smoking at all ages which has a section dedicated entirely to educational activities for students, with interactive lessons, meetings in cinemas, educational materials downloadable directly from the website to avoid that children remain passive in the face of the information they are given.
Project “Guadagnare salute con LILT”: the Italian League for the fight against Cancer supports preventive interventions and training initiatives that they promote psychophysical well-being, peer education and family awareness in schools of all levels.
The project is divided into different programs for preschool and primary schools (Infancy and health), for lower secondary school (well- being and health) and the LILT programs for upper secondary schools.
Project “Cuora il futuro”: on 7 August 2017, a Memorandum of Understanding on the prevention of drug and alcohol use in school age was signed between the Presidency of the Council of Ministers - Department of Drug Policies, and the Ministry of Education, University and Research - Department for the education and training system.
The project was set up from this collaboration and it aims to build a path of concrete actions and effective dissemination, aimed at fighting and preventing the use of drugs among the population. The project has a duration of two years, starting from the date foreseen by the school that activates it and through the implementation of educational programs and initiatives aimed at school students, but also at teachers and parents, the two-year project aims to implement a communication strategy, awareness and education on the prevention of drug use.
The platform is the main tool for the dissemination of the initiatives provided. Under the agreement signed with the Presidency of the Council of Ministers, Indire (National Institute of Documentation, Innovation and Educational Research) has the task of supporting the Miur in the realization of the training plan through the creation of online training for participating teachers and offering technical and planning support. Operational and consultation materials, legislation and documents will be published on the website, along with a reference bibliography and links to the main sites of interest. Indire will also take care of the informative campaign to students and families with a plan of targeted interventions aimed at spreading the message through various media (platform, brochures, press, TV, web, etc.).
EDU project, promoted by the Department of Drug Policies, in collaboration with the Ministry of Education, University and Research and with the United Nations Organization, promotes innovative tools for the prevention of drug use among young people, making them available to teachers and parents, so that they accompany young people towards positive and responsible choices. The EDU platform is an e-learning system responsible for providing teachers and parents new prevention tools that can be used and adopted in class to address the drug issue with children in a simple and understandable language. Two areas are available on this educational platform: one dedicated to teachers and one dedicated to parents. Each area provides the user with a training kit for the collection of scientific information for the implementation of activities to prevent the use of drugs at home or school. The training kit consists of electronic material available in various formats (slides, videos, documents, etc.) and can be used by the teacher/parent to acquire more skills on the consumption of alcohol, tobacco and drugs among young people and on how to prevent them being adopted. The platform also provides spaces for discussion between users and teachers/tutors who can further support teachers and parents in their training.
- Education about health and healthy lifestyles in schools
- Law 107/2015 (“Good school”) in Article 7 Point g. enhances the motor disciplines and promotes the development of behaviours inspired by an healthy lifestyle, with particular reference to nutrition, physical education and sport, and attention to protection of the right to study of students practicing competitive sports, through high-level student-athlete didactic experimentation (D.M. 279 10/04/2018).
- The Ministry of Health, together with the Ministry of Education, University and Research has prepared the document “Integrated policy guidelines for the school that promotes health”, approved on January 17, 2019 in the State-Regions Conference (Cf. paragraph 7.6). These two political-regulatory instruments have not imposed any obligation at the curricular level but have introduced a joint and continuous path that intends to formally include the promotion of health, well-being and the culture of safety and legality within the educational system of education and training through the launch of a series of projects including “Gaining health with LILT” and “Cuora il futuro”, summarized in the previous paragraphs.
Italy is one of the countries in which sex education was introduced late and, to date, there has not been sufficient consensus in favour of a national law that will make its teaching compulsory in schools.
- Peer education approaches
The LILT (Italian League for the Fight against Cancer) has launched a program aimed at the fourth and fifth years of high schools, “Change lifestyle and promote change with LILT”, consisting of a path of peer education on contrasting lifestyles at risk and a curricular didactic module on the following points: decision-making processes, problem solving skills; analysis of the individual reference values; conflict management; simulation of the different kinds of reaction with the use of the forum theatre; emotion management; creativity/divergent thinking: training to enhance the skills of using creative thinking for the solution of mathematical, existential and relational problems; adaptability.
A structured peer-to-peer education model has yet to be developed in Italy and the country does not have any guidelines that introduce this type of education as a form of learning for health and healthy lifestyles.
Collaborations and partnerships
The various political strategies and action plans on health and well-being are developed and implemented in close collaboration between the Central Government (through the different ministries), the Regions, the Autonomous Provinces, the National Association of Italian Municipalities (ANCI), the Higher Institute of Health (ISS), the National Institute for Occupational Accident Insurance (INAIL), the Council for Agricultural Research and Analysis of the Agricultural
Economy (CREA) and various associations and non-governmental organizations.
- Raising awareness on healthy lifestyles and factors affecting health and well-being of young people
In Italy, there are several initiatives and awareness campaigns on healthy lifestyles and the factors that affect their health and well-being:
The fruit and vegetable program in schools uses traditional media (radio, press, TV) to reach thegeneral public but has also developed a digital strategy that uses the main social networks and paid ads on Google, banner display and video ads on Youtube. For this program, in 2020, ISMEA (Institute of Services for the Agricultural Food Market) organized 4 live online events called “Batti il 5 con Frutta e verdura nelle scuole”.
“Charter of non-smokers” is a poster created for schools by the Umberto Veronesi Foundation in collaboration with the MIUR. It summarizes in ten points the important issue of protection from the damage of smoking in order to stimulate young people to a sense of responsibility with regard to smoking;
In compliance with the law n.125 / 2001 “Framework law on alcohol and related alcohol problems”, the Ministry of Health, in collaboration with the National Alcohol Observatory (Ona) of the Higher Institute of health care, in 2016, launched a communication campaign aimed at combating alcohol abuse, especially among young people. The messages promote the following values: freedom from external conditioning of the group and models proposed by the media and advertising, maturity in the choice of wanting to remain lucid mentally when living a situation of leisure, awareness of the possible direct and indirect damage to health related to alcohol abuse.
Among the tools used there is the advertisement “There are those who drink and who have fun. And you?”, which aims to deconstruct the behavioural model proposed by the media that associates the act of drinking with success, fun and charm, to belittle the idea of alcohol as a facilitator of socialization in the collective imagination, to propose the alternative of non-alcoholic conviviality, to promote and make the image of those who know how to control themselves attractive. As part of the collaboration with HBSC Italia (Health Behaviour in School-aged Children – Behaviours related to health in school-aged children) projects were realized:
- The multimedia educational kit, aimed in particular at high schools of both first and second level, created by the Ministry of Health, the Higher Institute of Health and the Ministry of Education university and research, with the aim of promoting knowledge and awareness of the problems in adolescent life;
- Promocards on smoking and alcohol, designed for a young target (ages 14-35). They use a type of information that is based on the use of messages with a youthful and provocative tone and attractive graphics. Among these:
- When you drink you become more expansive. Yes, because your belly swells.
- The breath of smokers takes your breath away. Worse than a cigarette.
- Rimmel on the eyelashes. Lipstick on the lips. Nicotine on the teeth.
- Two glasses. Two car keys. Two accelerators. Two roads. Two trees.