School feeding programs increase weight and school attendance of students.
Photos by: Yuri Kozyrev (R), Alejandro Lipszyc (L)
Why is school feeding important?
- Early malnutrition and/or micronutrient deficiencies can negatively affect children’s physical, mental and psychosocial health. These deficiencies have been linked to poorer cognitive functioning. School feeding programs are designed to improve attendance, achievement, growth and other health outcomes by providing food to socio-economically disadvantaged children in high- and low- and middle-income countries.
Does it work?
- In lower income countries, school feeding increases weight and school attendance, and may increase height gain. Children who were fed at school also improved math achievement more than controls who did not receive food at school.
Equity – does it work in the disadvantaged?
- All of the participants in the included studies were disadvantaged children therefore school feeding programs are effective at improving health and cognitive outcomes in disadvantaged children.
- School feeding programs may be more effective for more disadvantaged or malnourished children
Intervention Delivery
- The studies included in this review provided school feeding through meals (breakfast or lunch) or through snacks/milk.
- The review does not report on the effectiveness of delivery mechanisms, but found that timing of the meal may be important. Meals provided outside of regular school hours (i.e. breakfast) may have lower compliance.
Population and Setting
- All included studies were conducted in low-, and higher income countries with disadvantaged children.
Summary of Findings [SOF] Table: School feeding to improve the physical and psychosocial health of disadvantaged students
Patient or population: Disadvantaged children between ages 5 and 19
Settings: Schools in developed and developing countries
Intervention: School feeding
Comparison: No school feeding
Outcomes | Comparator (control) | Intervention vs. control mean difference | No of Participants | Quality of the evidence |
Developing Country |
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Weight gain (kg) – RCT | The mean weight gain in the control group ranged from 1.87 to 10.1 kg | MD 0.39 kg more (0.11-0.67) | 1462 (3) |
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Weight gain (kg) – CBA | The mean weight gain in the control group ranged from 0.97 to 2.28 kg | MD 0.71 kg more (0.48-0.95) | 984 (4) |
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Height gain (cm) – RCT | The mean height gain in the control group ranged from 3.38-12.2 cm | MD 0.38cm more | 1462 (3) |
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Height gain (cm) – CBA | The mean height gain in the control group ranged from 3.2 to 5.24 cm | MD 1.43 cm more (0.46-2.41) | 986 (4) |
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Full scale IQ – CBA | The mean full scale IQ for the control group was 95.8. | MD 3.90 points higher (-2.88-10.68) | 231 (1) |
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Developed Country |
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Weight gain (kg) – developed country | The mean weight gain in the control group was 5.12 kg | MD 0.13 kg more | 520 (1) |
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Height gain (cm) – developed country | The mean height gain in the control group was 9.18 cm | MD 0.28 cm more | 520 (1) |
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Adverse events: None reported | ||||
Relevance of the review for disadvantaged communities School feeding programs increase weight and school attendance of students. | |
Findings | Interpretation |
Equity – Which of the PROGRESS groups examined |
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The review reported subgroup analyses for age and sex but were unable to complete a planned subgroup analysis by socioeconomic status due to lack of SES stratified data. | The results found that school feeding programs may be more effective at younger ages, for students 5-6 or 9-10 years old. Policymakers may consider focusing on younger age groups for school feeding programs. |
There was generally little evidence for difference in effectiveness by sex. | One included study found that meals including protein (meat) resulted in greater weight gain in boys than girls. Another study found greater gains in height for girls. More studies are needed that examine whether different foods will affect boys and girls differently and ensure that there is a balance to ensure gains for both. |
Studies were conducted in both low and higher income countries. All of the participants were classified as disadvantaged. Low income country participants were ‘predominantly disadvantaged’ according to the following criteria: from rural area, from urban low SES community, or is 30% of the samples of children were underweight or stunted. Undernourished children, showed greater gains in short-term cognitive performance than well-nourished children. | The included studies suggest that school meals are more effective for those who are more in need. As such, implementation of the intervention may reduce inequalities. |
Equity Applicability |
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The review does not report on the effectiveness of different delivery mechanisms for school feeding. The studies included in this review provided school feeding through meals (breakfast or lunch) or through snacks/milk. | Many factors can impact the effectiveness of school feeding programs: the design of the program, the energy, protein and fat content of the provided meals or snacks, compliance with the program, and the home environment. Policy makers and practitioners will have to determine the most suitable delivery mechanism, frequency, and timing within the local setting. |
The review did not assess the role of co-interventions on effectiveness. However, school feeding is expected to have greater improvements if the learning and living environments of the children are also improved. Schools need to have basic amenities, such as adequate materials and supplies. | Other studies are needed for policy makers and practitioners to make decisions on how school feeding might relate to other nutritional, health and environmental interventions. School meals are an important tool to increase school attendance and nutrition. They should be used in combination with other interventions. |
Cost-equity |
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The review did not report on the cost-effectiveness of school feeding overall or in each disadvantaged group, due to insufficient data. | The cost of school feeding may be variable based on local conditions outside of research settings. Policymakers planning to implement school feeding need to consider the cost of the meals/snacks/milk to be provided as well as the other resources needed to prepare, serve, and store the food items. |
Monitoring & Evaluation for PROGRESS Groups |
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School meals resulted in small improvements in weight, school attendance, math performance, and behaviour. Improvements in height were seen mostly in children younger than eight years of age. | School feeding is recommended for increasing weight, school attendance, math performance, and behavior in disadvantaged students aged five to nineteen. |
To meet the needs of the target population, it is important that foods be appealing, culturally acceptable and locally available. Piloting a school feeding program is important to identify and address specific nutritional issues and needs of the target population. Effective delivery and process evaluation is important, as well as the encouragement of full participation. An unexpected adverse effect of school feeding is substitution. – The home diet may be reduced for children who receive food at school. This may reduce the effectiveness of school feeding. Other possible confounders are energy content of meals, and student compliance. | Implementation of a school feeding program needs to include an evaluation to ensure the effectiveness of the intervention. Policy makers need to monitor the program to ensure that possible adverse effects, such as substitution are detected as well as identify any other confounders. The studies from high-income countries found that compliance was lower than expected which will impact the program’s effectiveness. |